The World Bank Institute and Futures Group
in collaboration with
O’Hanlon Health Consulting, Tropical Health LLP, and
University of California at San Francisco
JANUARY 2014
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Session 5
Sustaining Universal
Coverage with Insecticide
Treated Nets to Prevent
Malaria
Albert Kilian
The World Bank Institute
in collaboration with
O’Hanlon Health Consulting, Tropical Health LLP and University of California at San Francisco
OVERVIEW
MALARIA PREVENTION WITH ITN
ITN IN TANZANIA 2008-2014
USING M4H TO REVISE STRATEGY
SUMMARY
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Overview
 This session builds on the introduction of the two
elements of the M4H approach
 Market Forces framework
 Health Market Systems framework
 Uses the Tanzania case for ITN beyond 2008 to
demonstrate the possible application of M4H to a
health product in a changing environment by
 Understanding the role of the product in public health
 Analyse the market forces and systems to understand
where the problems are and how they could be solved
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OVERVIEW
MALARIA PREVENTION WITH ITN
ITN IN TANZANIA 2008-2014
USING M4H TO REVISE STRATEGY
SUMMARY
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The Product – Mosquito Net
 For malaria control/elimination efforts only long-lasting
insecticidal nets (LLIN) are suitable products
 LLIN are special ITN that are “loaded” with insecticide so
that they can “re-treat” themselves after washing and use
Long-lasting
treatment kit
Mosquito net
Conventional
ITN
LLIN
Insecticide Treated Nets
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The LLIN Product
 Production process of LLIN varies for polyester (coating)
and polyethylene, polypropylene (incorporation)
 “Local” production of LLIN is only possible in collaboration
with patent/licence holders and has limitations (economy
of scale)
 Needs significant investment and Quality Control
 Occupational protection (insecticide)
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ITN and Malaria Prevention
 WHO strategy change in 2008:
 from individual protection to ITN as transmission
reduction
 Target now universal coverage
 At household level: 1 ITN for every 2 people
 At population level: 80% population with access to ITN
 With the development of the LLIN technology these
ITN have become the standard for public health
 Has made recent successes possible
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ITN and Malaria Prevention
 If initial ITN coverage is low, mass campaigns are the only
way to achieve rapid, equitable scale up
 But campaigns are not ideal to sustain gains
 Continuous distribution systems have advantages
 Multiple channels (donors), increasing contribution of market
 Repeated exposure to BCC message (net culture)
 Provide new LLIN when and where needed
NetCALC output
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The Role of the Public Sector
 In the past often heated debates on whether nets/ITN
should be free or sold at (some) cost
 The actual question may be more about the role of the
public sector and government
 Central planning and taking decisions for individuals or
families
 Allowing for initiative and responsibility and ensuring
adequate environment and access to health services and
products
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The Family at the Center
Public Sector
Civil Society
Perceived
risk of
malaria
Subsidized
Free
Multichannel BCC
Family
Social Norms
Need
Demand
Access to
LLIN
At cost
Perceived
barriers &
benefits
Subsidized
Experience
of disease
Private Sector
Markets
Source: Kilian A, Koenker H, NetWorks Project
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Post-campaign Demand & Sustainability
After campaign need begins to grow which can be turned into demand
“Pull systems”, demand driven should increasingly dominate CD strategy
Contribution of commercial sector will be country and time dependent
Demand
100%
90%
Households with at least 1 ITN



80%
70%
Pull
Pull
60%
50%
Campaign
Push
Pull
ANC
40%
30%
Push
20%
10%
0%
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Years
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Conclusion
 Comprehensive, multi-channel continuous ITN
distribution systems have the best chance for long
term success
 Involving all sectors of society with increasing
contribution of market systems
 Allowing initiative and responsibility
 Less vulnerable to changes in funding
 For this to happen repeated campaigns should be
avoided and remain a “last resort” and public sector
needs to engage in dialogue with private sector
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OVERVIEW
MALARIA PREVENTION WITH ITN
ITN IN TANZANIA 2008-2014
USING M4H TO REVISE STRATEGY
SUMMARY
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The Tanzania Case
Phase 2: 2008-2014
 Shift to LLIN
 Shift to “universal coverage”
 A to Z LLIN factory for local production





Free mass campaign U5 2009
Universal coverage top-up campaign 2010
Shift voucher scheme to LLIN only (one brand)
Change voucher from fixed value to fixed top-up
Dialogue and new strategy :
 Test school distribution system (push) in Southern Zone
 Invite other LLIN brands to participate in the voucher
scheme
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The Tanzania Case
MIS 2007
UCC
U5CC
Phase 2: 2008-2014
MIS 2011
SNP (pilot)
Voucher Scheme
Private sector
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The Tanzania Case
Coverage and equity of ITN ownership and use
National
Any ITN: 39%
Access to ITN: 26%
National
Any ITN: 91%
Access to ITN: 75%
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The Tanzania Case
Coverage of ITN ownership and use in 2013
Voucher
scheme
Schools + Voucher
scheme
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Situation 2014 - Public
 As anticipated, the voucher scheme is not enough to
sustain the success of the campaigns, coverage is
dropping significantly (except in Southern Zone with
school program)
 Current funds for vouchers will end in 2015, and, donors
are hesitant to commit further funding
 Overall funding is expected to decline and it is not clear
that the annual need of approx. 5-7 million LLIN can be
funded
 Government with funding from Global Fund plans
another mass campaign for 2015 (except Southern
Zone)
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Situation 2014 – Net/ITN Market
 The voucher scheme has still approx. 6500 retailers
under contract, with sales of 1.8 million LLIN in 2013
 A to Z has 95% market share of the voucher scheme
(one small competitor)
 There are hardly any LLIN sales outside the voucher
scheme, no other LLIN brands, but products leaked from
campaign and/or neighboring countries
 Of the four original net manufacturers, two (including A
to Z) still market untreated nets (sales ~ 1 million/year)
without treatment kits
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Way Forward




At stakeholders meeting April 2014 consensus emerged
Commit to a comprehensive LLIN distribution system
Maintain voucher scheme for high risk groups
Roll-out school distribution nationally after next mass
campaign
 Abstain from future mass campaigns
 Support development of a viable LLIN market
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OVERVIEW
MALARIA PREVENTION WITH ITN
ITN IN TANZANIA 2008-2014
USING M4H TO REVISE STRATEGY
SUMMARY
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Vision for Markets
 Untreated net market shrinks … disappears
 Viable distribution market for LLIN with supply chain
independent of the voucher scheme
 Multiple brands, distributors
 Variety of products (choice)
 High quality LLIN products (no counterfeits)
 Increasing penetration of LLIN retail market into rural
high risk areas
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Market forces
Unstructured Market
Campaign
OPERATIONAL AUTONOMY
0%
100%
CUSTOMER COMPETITION
0%
100%
PRICE INFLUENCE
Administered
Market
ENTRY BARRIERS
Very High
0
SOCIAL FUNDING
100%
0
PERFORMANCE TENSION FOR/UNDER CONTRACTS
No contracts
No tension
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Market forces
Campaign
Voucher Scheme
Unstructured Market
OPERATIONAL AUTONOMY
0%
100%
CUSTOMER COMPETITION
0%
100%
PRICE INFLUENCE
Administered
Market
ENTRY BARRIERS
Very High
0
SOCIAL FUNDING
100%
0
PERFORMANCE TENSION FOR/UNDER CONTRACTS
No contracts
No tension
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Market forces
Campaign
Desirable LLIN market
Unstructured Market
OPERATIONAL AUTONOMY
0%
100%
CUSTOMER COMPETITION
0%
100%
PRICE INFLUENCE
Administered
Market
ENTRY BARRIERS
Very High
0
SOCIAL FUNDING
100%
0
PERFORMANCE TENSION FOR/UNDER CONTRACTS
No contracts
No tension
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Markets systems
Public-Private
Dialogue
Related
Services
Information
R&D
Subsidy
Purchase
Quality
Assurance
Invest
Infrastructure
Providers S
LLIN Retail
D Consumers
Standards
 Public-private dialogue and
commitment to malaria
prevention remains the most
critical factor
 Involve also Business
Coalition, Corporate
Responsibility Programs
Laws
Regulations
Informal Rules
and Norms
Rules
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Markets systems
Potential structuring interventions to be explored
Public-Private
Dialogue
Related
Services
Information
R&D
Subsidy
Purchase
Quality
Assurance
Invest
Infrastructure
Providers S
LLIN Retail
D Consumers
Standards
 Strengthen QA system
 BCC campaign to increase
value of LLIN
 Generic marketing for LLIN
brands
 Engage A to Z to phase out
production of untreated nets
 Minimize leakage from public
sector
Laws
Regulations
Informal Rules
and Norms
Rules
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Markets systems
Potential structuring interventions to be explored
Public-Private
Dialogue
Related
Services
Information
R&D
Subsidy
Purchase
Quality
Assurance
Invest
Infrastructure
Providers S
LLIN Retail
D Consumers
Standards
Laws
Regulations
 Provide temporary and smart
subsidy for LLIN distributors
 Continue targeted subsidy for
high risk groups
 Facilitate/invest in shift of local
net manufacturers to LLIN
production
 Facilitate institutional sales to
large employers
Informal Rules
and Norms
Rules
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Markets systems
Potential structuring interventions to be explored
Public-Private
Dialogue
Related
Services
Information
R&D
Subsidy
Purchase
Quality
Assurance
Invest
Infrastructure
Providers S
LLIN Retail
D Consumers
Standards
 Negotiate accelerated
registration for new WHOPES
recommended LLIN brands
 Strengthen social norm for LLIN
use, care & repair and
replacement
 Ensure taxes and tariffs remain
favorable for LLIN market
Laws
Regulations
Informal Rules
and Norms
Rules
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OVERVIEW
MALARIA PREVENTION WITH ITN
ITN IN TANZANIA 2008-2013
USING M4H TO REVISE STRATEGY
SUMMARY
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Summary
 ITN market systems can significantly contribute to a
long-term solution on the way to malaria prevention and
elimination
 However, this requires commitment of public sector to a
long-term strategy that allows a role for markets (no
repeat campaigns)
 Strong public-private dialogue is key
 The M4H approach provides suitable tools to define the
desirable market situation (market forces) and
undertake comprehensive and holistic situation analysis
to identify potential interventions
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Thank You