Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002

Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002


National ITN Implementation National ITN Implementation PlanPlan

Achieving nation-wide ITN usage in the Achieving nation-wide ITN usage in the United Republic of TanzaniaUnited Republic of Tanzania

National Malaria Control ProgrammeNational Malaria Control Programme

TanzaniaTanzania


Estimated Population at Risk of Estimated Population at Risk of Malaria – Tanzanian - 2000Malaria – Tanzanian - 2000

• Population– Total 33.8 million (100%)

– At risk of malaria 31.6 million (93.7%)

• Population at risk where transmission lasts:– >6 months (stable, perennial) 14.1 m (42%)

– 4-6 months (stable, seasonal) 11.3 m (33%)

– 1-3 months ( strongly seasonal/epidemic) 2.6 m (8%)

– <1 month (epidemic/no malaria in avg.Year) 5.8m (17%)


Malaria:• Estimated 16 million malaria cases per year• Consumes 119 million US $ per year

(3.4%GDP) • Most deaths in under-five children and

pregnant women• Under 5 year child deaths estimated at

161,000 (per 1000 live births) per year of which 39,000 due to malaria

Tanzania’s Burden of DiseaseTanzania’s Burden of Disease


ITN EffectivenessITN Effectiveness

• Results of large scale ITN trials in Africa:Results of large scale ITN trials in Africa:– Overall Overall 20% reduction20% reduction in ‘all cause’ child in ‘all cause’ child

mortalitymortality– Overall Overall 50% reduction50% reduction in malarial illness in malarial illness– Effective at all levels of transmissionEffective at all levels of transmission– 5.6 deaths averted per 1000 children per year5.6 deaths averted per 1000 children per year– Despite < 70% complianceDespite < 70% compliance


ITN EffectivenessITN Effectiveness

• KINET evidence – for treated net users:KINET evidence – for treated net users:– Childhood Childhood (1 month – 4 years)(1 month – 4 years) protective efficacy of 27% protective efficacy of 27% – 63% less parasitaemia 63% less parasitaemia – 63% less anaemia63% less anaemia– Children generally healthier and grow betterChildren generally healthier and grow better– Protected pregnant women 12% less anaemiaProtected pregnant women 12% less anaemia– Despite low re-treatment rates in an area of perennial Despite low re-treatment rates in an area of perennial

transmission with very high biting ratestransmission with very high biting rates

• For children under 5 alone this could translate into For children under 5 alone this could translate into more than 30,000 deaths averted per year in more than 30,000 deaths averted per year in TanzaniaTanzania


Why ITNs in TanzaniaWhy ITNs in Tanzania ? ?

• High needHigh need• Strong research-based effectiveness evidenceStrong research-based effectiveness evidence• Cost-effectiveness advantageCost-effectiveness advantage• Public sector becoming more responsive Public sector becoming more responsive • Energetic private sector Energetic private sector • Expanding district level involvementExpanding district level involvement• NGOs engaged and willingNGOs engaged and willing• Renewed commitment from donor partnersRenewed commitment from donor partners• Evidence of increased household expenditure Evidence of increased household expenditure


Where do we want to go ?Where do we want to go ?

High utilization of ITNs through more equitable access

What does this mean for Tanzania ?What does this mean for Tanzania ?• Present coverage –

– <50% of children sleep under any net– Coverage of ITNs is greater, in project areas (up to 30%)

when compared to non project areas– Areas with ITN projects, 13 – 28 % ITN coverage– Overall net usage 80% in some towns, 50% in rural areas


TargetsTargets

By 2007: at least 60 % of children under 5 By 2007: at least 60 % of children under 5 years of age and pregnant women will be years of age and pregnant women will be sleeping under an appropriately treated sleeping under an appropriately treated mosquito net mosquito net


How to meet Public Health Need?How to meet Public Health Need?

• Donors and Government unable to meet costs of Donors and Government unable to meet costs of project type social marketingproject type social marketing

• Commercial sector is already successfully Commercial sector is already successfully marketing Nets and treatment kitsmarketing Nets and treatment kits

• Local commercial distribution is more efficient Local commercial distribution is more efficient than projects than projects (mark-up $2-$4)(mark-up $2-$4)

• Must use public funds in the most effective wayMust use public funds in the most effective way• So - Need to target resources to those most at risk So - Need to target resources to those most at risk

without reducing commercial saleswithout reducing commercial sales


Public Sector ITN Distribution Public Sector ITN Distribution ??• Attractive opportunity – promote and sell Attractive opportunity – promote and sell

nets at clinicsnets at clinics• Revolving funds at clinic / district level Revolving funds at clinic / district level

hard to administer – large losses reportedhard to administer – large losses reported• Temptation to take excess profit so cost not Temptation to take excess profit so cost not

reducedreduced• Public Health facilities is not the best option Public Health facilities is not the best option

for delivery of ITNsfor delivery of ITNs


Commercial Sector involvementCommercial Sector involvement

• Sales grown to more than 1.5 Sales grown to more than 1.5 million per year million per year through existing through existing commercial networkscommercial networks – mainly – mainly urbanurban

• Combined production of the three Combined production of the three net manufacturing companies – 4 net manufacturing companies – 4 million nets per annummillion nets per annum

• Key partnerships with insecticide Key partnerships with insecticide producers – kit price now $ 0.35producers – kit price now $ 0.35

• Retail price of nets: $2.6 – $3.6Retail price of nets: $2.6 – $3.6


Enabling FactorsEnabling Factors

• Establishment of ITN Multisectoral Task Establishment of ITN Multisectoral Task ForceForce

• Strong local research base Strong local research base • Strong and growing manufacturing sectorStrong and growing manufacturing sector• Donors prepared to invest and encourage Donors prepared to invest and encourage

manufacturers through demand creationmanufacturers through demand creation• Dynamic, committed, social marketing teamDynamic, committed, social marketing team• Committed individuals supporting Committed individuals supporting

development of plan – development of plan – NMCP, MoH, Researchers, NMCP, MoH, Researchers, Private sector, NGOs, donors.Private sector, NGOs, donors.


Enabling FactorsEnabling Factors

• Removal of taxes and tariffs on both nets Removal of taxes and tariffs on both nets insecticidesinsecticides


ChallengesChallenges

• Advocacy – reaching a critical mass Advocacy – reaching a critical mass • Sustainability of the momentum which has Sustainability of the momentum which has

substantial donor support substantial donor support • Concurrent activity when human resources Concurrent activity when human resources

are over stretchedare over stretched• Net use in rural areas is still strongly Net use in rural areas is still strongly

seasonal, yet malaria transmission is all seasonal, yet malaria transmission is all year roundyear round


ChallengesChallenges

• Reaching those who truly may not be able Reaching those who truly may not be able to afford a netto afford a net

• Balancing public health gain and private Balancing public health gain and private cost cost


SoSo

The way forwardThe way forward


Strategic ApproachStrategic Approach

• Demand creation - Demand creation - Government / Donor funded and Government / Donor funded and contracted outcontracted out

• Production, distribution, sales - Production, distribution, sales - Private sectorPrivate sector

• Regulatory coordination - Regulatory coordination - Government (NMCP) and Government (NMCP) and regulatory instruments of the govt.regulatory instruments of the govt.

• Monitoring and Evaluation / Research - Monitoring and Evaluation / Research - GovernmentGovernment (NMCP)(NMCP) coordinated / contracted out / coordinated / contracted out / research partnersresearch partners

• ITN Steering Committee - ITN Steering Committee - Multi-stakeholderMulti-stakeholder

• Coordination and Management –Coordination and Management – NMCP basedNMCP based


Implementation PlanImplementation Plan

• ITN Steering Committee formed from Task ITN Steering Committee formed from Task Force Force – Responsible to MoHResponsible to MoH

• CMO and NMCP Manager on Steering CMO and NMCP Manager on Steering Committee Committee

• Implementation Team a ‘cell’ within NMCPImplementation Team a ‘cell’ within NMCP• Implementation Team Leader reports to Implementation Team Leader reports to

Steering Committee Steering Committee


Implementation Team RoleImplementation Team Role

• Advocacy / NegotiationAdvocacy / Negotiation

• Management of processManagement of process– Demand creation co-ordination / contractingDemand creation co-ordination / contracting– Research co-ordination / contractingResearch co-ordination / contracting– Management of Voucher schemeManagement of Voucher scheme– Regulatory / Revenue lobbyingRegulatory / Revenue lobbying

• Financial managementFinancial management

• Technical advice / support to DistrictsTechnical advice / support to Districts


Public / Private partnershipPublic / Private partnership

• Implementation Team role to:Implementation Team role to:– Co-ordinateCo-ordinate– FacilitateFacilitate– NegotiateNegotiate– Broker agreementBroker agreement


Role of Social Marketing Role of Social Marketing

• Concentrates on commercial alliances to Concentrates on commercial alliances to increase net availability in rural areasincrease net availability in rural areas

• Promotes a ‘national brand’ of Insecticide Promotes a ‘national brand’ of Insecticide (Ngao) for a variety of different net (Ngao) for a variety of different net treatments – consumer confidence and treatments – consumer confidence and recognition, while encouraging competition recognition, while encouraging competition to reduce cost.to reduce cost.


Evolving Partner ContributionsEvolving Partner Contributions

PRIVATE

PUBLIC SECTOR

Demand Creation

Distribution

Distribution

NGOs

Household / communitydemand creation

Equity &Vulnerable groups

Create enabling environment

Distribution

Production

Consumerinformation

Research Partners

Donor Partners

STARTSTART


Consumerinformation

PRIVATESECTOR

PUBLIC SECTOR

NGOs

National generic demand creation Brand specific demand creation

Household / communitydemand creation

Supply & Sales

Productdevelopment

Equity &Vulnerable groups

National co-ordination

Consumer protection - regulatory issues

Distribution

Distribution

Create enabling environment

Desired Framework for PartnersDesired Framework for Partners

DONOR PARTNERS

Demand Creation

RESEARCH PARTNERS


2000

2002

2005

2007 Market mature, NMCP subsumes role of Implementation Team. ITN projects, except equity based, phased out. Evaluation, monitoring and essential promotion MoH

funded. Social Marketing

(promotion)

Social Marketing(promotion and

distribution)

Social Marketing(promotion, distribution

and advocacy)

KINET

andother equity based projects

Market MaturingImplementation TeamOperational: Advocacy,technical support,Contracting of activities to Private sector.

Implementation team fundedMarket Forming

Core activities of Social Marketing within evolution of ITN Implementation Plan

10%

50%

70%

CoverageCoverage


The availability of Nets and The availability of Nets and Insecticides in the country Insecticides in the country

• Maximum choice of ITN commoditiesMaximum choice of ITN commodities

• Facilitated co-operation between TPRI / Facilitated co-operation between TPRI / TBS and net/insecticide manufacturers TBS and net/insecticide manufacturers

• Nets bundled with InsecticideNets bundled with Insecticide

• Agreement reached that all netsAgreement reached that all nets sold will sold will be be with insecticidewith insecticide (c.f. iodised salt) (c.f. iodised salt)

• Insecticide kitsInsecticide kits


GFATM proposal for malariaGFATM proposal for malaria

• Equitable targeting to highest risk groups Equitable targeting to highest risk groups – Pregnant women and infants Pregnant women and infants

• Voucher systemVoucher system– linked to uptake of essential health interventionslinked to uptake of essential health interventions

• antenatal clinic attendance, EPI uptakeantenatal clinic attendance, EPI uptake

– high value to encourage uptakehigh value to encourage uptake– MCH staff distribute, Banks cash voucherMCH staff distribute, Banks cash voucher


VouchersVouchers

• benefits benefits – encourages private sector sales and rural encourages private sector sales and rural

penetrationpenetration

– will not destabilise marketwill not destabilise market

– readily identifiable qualification readily identifiable qualification (pregnancy)(pregnancy)

– less administration for health staffless administration for health staff

– could pull antenatal and EPI coverage upcould pull antenatal and EPI coverage up


VouchersVouchers

• risks risks – Fraud, high value Fraud, high value high risk high risk

– Retailer refusal to honour voucherRetailer refusal to honour voucher

– Banks refusal to co-operateBanks refusal to co-operate

– Retailers don’t get moneyRetailers don’t get money

– Who uses the ITN in the home ?Who uses the ITN in the home ?


Subsidy – Research GapsSubsidy – Research Gaps

• Market research - who truly still needs subsidyMarket research - who truly still needs subsidy• Commercial sector slow to engage in the process Commercial sector slow to engage in the process

(voucher scheme)(voucher scheme)• Extent of Black market (leakage of voucher) Extent of Black market (leakage of voucher) • Definition of criteria for access ?Definition of criteria for access ?• Monitoring and Control systems ?Monitoring and Control systems ?• Audit Audit • Cost ? Risks ?Cost ? Risks ?


Accelerated AccessAccelerated Access

• RequiresRequires– Massive effortMassive effort– Significant extra resources Significant extra resources

• GFATM approvalGFATM approval

• Bilateral support is time limited Bilateral support is time limited

– New ways of workingNew ways of working• Contracting outContracting out

• Private sector skills Private sector skills public sector public sector

• Stakeholder co-ordinationStakeholder co-ordination


District ActivitiesDistrict Activities

• Persistent behaviour change requires:Persistent behaviour change requires:– Integrated district / community activities that Integrated district / community activities that

encourage adoption of new ideasencourage adoption of new ideas


BUT - Who makes the choices ?BUT - Who makes the choices ?

• Community Community empowermentempowerment

• Changing behaviourChanging behaviour• Empowering womenEmpowering women• Income generationIncome generation• Fair pricingFair pricing


• Prioritising health Prioritising health needs – knowledge needs – knowledge basedbased

• Local availability of Local availability of low cost ITN supplieslow cost ITN supplies

• Economic gains from Economic gains from reduced malaria reduced malaria burdenburden

• Increased human Increased human capitalcapital

• Maintain long term Maintain long term viewview

ConsumersConsumers


AHSANTE SANAAHSANTE SANA

Documents

Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002