Universal Access to Effective Malaria Prevention and Treatment:

how do we get there?

Sunil MehraExecutive Director, Malaria Consortium

with contributions from Dr. Albert Kilian, Dr. Sylvia Meek, Dr. Graham Root,

and Caroline Vanderick

Beyond Scaling Up

MALARIA - IntroductionMalaria control rests on two major pillars

Within the prevention arm Long-Lasting Insecticidal Nets (LLIN) form the most important intervention in sub-Saharan Africa

Parasite Vector

Host

EnvironmentEnvironmentIRS

LLIN

EnvironmetalManagement

Treatment

IPTp

IPTi

PreventionCase Management

Prevention with LLIN� For many years the RBM Working Group on ITN (now Vector

Control WG) has suggested a mixed model approach to scaling up ITN

� However, actual implementation did not take off due to lack of donor commitment 2003-05

Long term targeted subsidies for most vulnerable

Short term subsidies to encourage ITN market growth

Unsubsidized commercial expansion for sustainability

Donor funding

Domestic funding

Time

2003

2010

Saving Lives, Sustaining Gains

Nigeria: Support to the National Malaria ProgrammeCNTR 2007 07843

Malaria Consortium Partnership2006

Our Vision

Vulnerable groups are protected with LLINs and accesseffective treatment through public and private channels.

Informed households, including poor, demand for and canobtain free or affordable LLINs

Increased demand encourages many suppliers, competition keeps prices low; and rural and community-

based distribution systems expand.

The burden of malaria declines especially amongst the poor.

Public Health, Private Markets

Approach

Public health private markets extends the potential of each sector through an inclusive and pluralistic approach

Public Health Private Markets Aiming for sustained total coverage

Public Sector

Improving delivery of health services,

setting policies, stewardship

Civil Society

Focus on the poor and marginalised

Commercial Sector

Improving access through competition

Each sector has unique strengths

All contribute to public health, none alone can achieve total coverage

Balance of components

Key strategy: demand creation and a blended distribution system for sustained and equitable

impact

Ensures equity and targeting

Achieves rapid results

Helps open up mass market demand

Public and civil society

sector component

4.4 million free LLINs through

campaigns

SMoH supported to distribute

5 million LLINs through ANC

Quality of care improved in

6,500 health facilities

30 million doses of SP for IPT

provided

Mass market response and lower pricing leads to long-term sustainability

Commercial sector support

10 million subsidised LLINs

through commercial sector

9.5 million subsidised <5yrs

ACTs at 10 cents each

Creation of sustainable demand & supply across all populations

Attaining and Sustaining Coverage

The Evidence from Kenya

Reviewed three different distribution models1. Traditional social marketing model by PSI2. Health facility based distribution of subsidised nets ($0.70)3. Campaign distribution of free ITNs to under-fives

Two key findings1. Only campaigns able to reach high coverage levels quickly2. Campaigns can reach the poor

DFID five year support to ITN social marketing in Kenya

1. Had limited impact on coverage / ‘access’2. Impacted negatively on the real commercial sector

MCP Approach to Coverage

• Kenya data confirms a key element of the MCP approach – campaigns are necessary

• MCP recognises that a mixed model is essential to not only rapidly increase coverage but also to sustain it

• Rapid increase– Free campaigns

• Sustain high coverage– Routine free distribution through ANC and health facilities– Improved access to LLINs through the commercial sector at

an affordable price

• Developed by Malaria Consortium M&E and Research Department

• Model estimates required inputs to attain and sustain coverage levels for LLIN/ITNs

• Model validated against real data from our Uganda and Mozambique programmes

• Currently being used by RBM partners

• RBM adopted our model to forecast LLIN/ITN needs across Africa

Malaria Consortium

Sustaining LLIN/ITN Targets Model

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 2 4 6 8 10 12 14 16 18

Time in years

Pro

po

rtio

n o

f n

ets

sti

ll in

use Polyethylene

Polyester

Malaria Consortium Sustaining LLIN Targets Model

Dynamic Loss Function

Nigeria: total expected net output in 12 project states

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

1 2 3 4 5

Year

Ne

t o

utp

ut

campaign

routine

LLIN subsidy

unsubsidized

Nigeria – 12 project states

Campaigns children under 5

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

9,000,000

10,000,000

0 1 2 3 4 5

Year

Nu

mb

er

of

ne

ts d

istr

ibu

ted

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Pro

po

rtio

n o

f h

h w

ith

at

lea

st

on

e n

et

in %

total net output

commercial

ITN coverage

Nigeria – 12 project states

Campaigns children under 5 + ANC

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

9,000,000

10,000,000

0 1 2 3 4 5

Year

Nu

mb

er

of

nets

dis

trib

ute

d

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Pro

po

rtio

n o

f h

h w

ith

at

leas

t o

ne

ne

t in

%

total net output

commercial

ITN coverage

Nigeria – 12 project states

Campaigns children under 5 + ANC + commercial subsidy

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

9,000,000

10,000,000

0 1 2 3 4 5

Year

Nu

mb

er

of

ne

ts d

istr

ibu

ted

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Pro

po

rtio

n o

f h

h w

ith

at

lea

st

on

e n

et

in %

total net output

commercial

ITN coverage

Nigeria – 12 project states

Campaigns children under 5 + ANC + commercial subsidy + unsubsidized

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

9,000,000

10,000,000

0 1 2 3 4 5

Year

Nu

mb

er

of

nets

dis

trib

ute

d

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Pro

po

rtio

n o

f h

h w

ith

at

leas

t o

ne

ne

t in

%

total net output

commercial

ITN coverage

Sustaining LLIN/ITN Targets Model

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

5,000,000

5,500,000

6,000,000

6,500,000

7,000,000

7,500,000

8,000,000

8,500,000

9,000,000

9,500,000

10,000,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Year

Nu

mb

er

of

ne

ts d

istr

ibu

ted

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Pro

po

rtio

n o

f h

h w

ith

at

lea

st

on

e n

et

in %

actual distribution

projected

ITN coverage

Uganda: modelling scenarios of distribution

DHS 2000/01

1.6%

DHS 2006

15.9%

Campaign distributions to all U5 & PW every 5 years, 50% polyethylene, 50% polyester

Uganda: modelling scenarios of distributionInitial campaign U5 & PW then 80% of PW-ANC, 50% polyethylene, 50% polyester

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

5,000,000

5,500,000

6,000,000

6,500,000

7,000,000

7,500,000

8,000,000

8,500,000

9,000,000

9,500,000

10,000,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Year

Nu

mb

er

of

ne

ts d

istr

ibu

ted

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Pro

po

rtio

n o

f h

h w

ith

at

lea

st

on

e n

et

in %

actual distribution

projected

ITN coverage

Uganda: modelling scenarios of distributionInitial campaign U5 & PW then 80% of PW-ANC plus 25% of households buy,

50% polyethylene, 50% polyester

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

5,000,000

5,500,000

6,000,000

6,500,000

7,000,000

7,500,000

8,000,000

8,500,000

9,000,000

9,500,000

10,000,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Year

Nu

mb

er

of

ne

ts d

istr

ibu

ted

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Pro

po

rtio

n o

f h

h w

ith

at

lea

st

on

e n

et

in %

actual distribution

projected

ITN coverage

Reaching the Poor

The Evidence from Kenya

Noor et al, 2007

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Cumulative % of all households by wealth quitile

Cu

mu

lati

ve

% o

f h

ou

se

ho

lds

wit

h i

nte

rve

nti

on

by

wea

lth

qu

inti

le Equity line

Com LLIN

Pub LLIN

SM LLIN

Concentration Curve

Concentration Index

Public -0.11

Commercial +0.11

Social Marketing +0.42

Equity of LLIN by Distribution Mechanism

The Evidence from Mozambique

Reaching the Poor - Prevention

• Kenya evidence

– Shows free campaigns are pro-poor

– Shows inequity of single-branded social marketing

• Mozambique evidence

– Shows free ANC and campaign distributions are pro-poor

– Show reasonable equity for commercial sector

– Shows inequity of single-branded social marketing

The reach of our partnershipDistribution Networks

CHAN MediPharm –Depots serving all six

zones

Rosies Textiles –

distribution network

for SE, SW and Kano

C.Zard – over 150 retailers country-wide

Springfields/Afcott –extensive cotton farmers network

Patemglobal –

nationwide

distribution network

Harvestfield –extensive distribution network in south

Pharmaceutical

manufacturers – well

structured networks

Price Support for Sustainability

Price Support

• Price support is channelled through the commercial sector

• Implementing agency does not retain the price support/subsidy

• Pioneering approach: done in Uganda and Mozambique by MC

• Price support aims to:– Reduce the price of quality/qualified LLINs

– Increase competition and choice

– Extend the market reach

– Support the development of a viable and expanding market

Price support – does it work?

• Malaria Consortium experience in Mozambique and Uganda :

– Increased commercial sector sales of LLINs

– Increased number of brands on market

– Reduced retail price of LLINs to compete with conventional untreated (and often poor quality) nets

– Commercial sector sales rose at a time of mass free LLIN distributions

MCP commercial partners’ ITN sales, Mozambique

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

200,000

220,000

240,000

260,000

280,000

300,000

320,000

340,000

NO

V

DE

C

JA

N

FE

B

MA

R

AP

R

MA

Y

JU

N

JU

L

AU

G

SE

P

OC

T

NO

V

DE

C

JA

N

FE

B

MA

R

AP

R

MA

Y

JU

N

JU

L

AU

G

SE

P

OC

T

NO

V

DE

C

2005 2006 2007

Cu

mu

lati

ve I

TN

sa

les

institutional

retail

Examples of commercial sector development

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Pro

po

rtio

n o

f n

ets

LL

IN

0

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

3,500,000

4,000,000

4,500,000

5,000,000

To

tal

nu

mb

er

of

nets

public and civil society

social marketing

commercial partners

estimated informal market

% LLIN

Uga

nda

Rapid Scale-up

� Since 2005 increasing investments and since 2008 good progress in many countries

� Based on modelling and practical experience clear indication that only mass campaign style distributions can achieve rapid scale-up towards universal coverage

Limitations of CampaignsHowever, loss of nets through “wear and tear” and other behavioural

factors starts early

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Years

Ho

useh

old

s w

ith

at

lea

st

1 IT

N

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0

10

20

30

40

50

60

70

80

90

100

0 1 2 3 4 5 6 7 8

Years

Togo

Sofala - Moz

Manica - Moz

Law ra - Ghana

Model Field data

Limitations of CampaignsEven repeated campaigns can not sustain high levels of coverage in an continuous fashion

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Years

Ho

us

eh

old

s w

ith

at

lea

st

1 IT

N

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Need for continuous distributions

� Distributions are needed that supply LLIN to target groups and/or customers in a continuous manner over long periods of time

� To reach new families

� To replace torn, lost or destroyed nets

� To fill gaps in family demand for nets not covered by campaign distributions

� To satisfy demand for choice (size, shape, colour of nets)

Channels for continuous distributions

� Primary distribution mechanisms are� Routine health services (ANC/EPI)

� Commercial retail market

� Unsubsidized

� Subsidized through “total market approach”

� Additionally and/or in places were neither health services nor the market can reach the population alternatives must be developed

� Through community based approaches

� Schools

� Religious institutions

Sustaining high coverageModelling suggest that this mixed approach will sustain

high coverage (emerging support from data)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Years

Ho

us

eh

old

s w

ith

at

lea

st

1 IT

N

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ANC 85% & 40% hhANC 85% & 20% hh

Single campaign

The role of commercial sectorEmerging data from Uganda and Nigeria seem to support this

8.9

5.2

4.0

0

1

2

3

4

5

6

7

8

9

10

Adjumani Kano

% o

f h

ou

se

ho

ld b

uyin

g c

om

me

rcia

l n

et

aft

er

free

ne

t

ANC

Campaign

Within 5 months of free distribution 4-9% of householdsprocured an additional net from the commercial market

Some Results

Distributing LLIN

10,000 47,135 144,512

657,612

3,382,287

5,654,329

8,904,048

0

1,000,000

2,000,000

3,000,000

4,000,000

5,000,000

6,000,000

7,000,000

8,000,000

9,000,000

10,000,000

2003 2004 2005 2006 2007 2008 2009

Sudan, 188,100, 2%

Southern Sudan, 399,320, 4%

Mozambique, 2,657,731, 30%

Uganda, 3,773,897, 43%

Nigeria, 1,885,000, 21%

Number of LLIN distributed by MC Contribution of countries

Retention of LLIN after 6 Months

0

10

20

30

40

50

60

70

80

90

100

Adjumani Jinja Katakwi Kitgum Gulu Cabo

Delgado

Inhambane Nampula Manica Sofala

Pro

po

rtio

n o

f n

ets

reta

ine

d

Uganda Mozambique

Equity of distribution

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Cumulative percentage of wealth quintiles in sample

Cu

mu

lati

ve p

erc

en

tag

e o

f w

ealt

h q

uin

tile

s

am

on

g h

h w

ith

pers

on

to

net

rati

o <

=2.0

equity line

distribution

Concentration Curve Uganda ANC and campaign

Concentration Curve Mozambique, ANC

0

10

20

30

40

50

60

70

80

90

100

0 10 20 30 40 50 60 70 80 90 100

Cumulative percentage of households

Cu

mu

lati

ve p

erc

en

tag

e o

f h

ou

seh

old

s w

ith

in

terv

en

tio

n

Favouring the-poor

Impact of LLIN

0

10

20

30

40

50

60

70

80

90

100

0 1 2 3 4 5 6

Age in years

Pro

po

rtio

n w

ith

ma

lari

a p

ara

sit

es

1994

1997

1998

2007

2008

Monitoring area Kamwenge, Uganda

Increased accessto health services

ACT introduced

LLIN campaign

The New Paradigm

• What do we mean?

– Global recognition of malaria problem

– Sufficient financing available

– Lofty ambitions

– Move from focus on burden reduction to focus on transmission reduction

• What must this translate into?

– Converted into successful malaria control

– Particularly higher transmission countries.• The heartland.

Scaling up and beyond

• Aggressive promotion of single solutions– GFATM funding forcing policy (examples?)

– LLIN delivery through measles campaigns

– Home-management of malaria (one disease system)

• Toward single models for delivery

• Blunt instrument

• Some value:– Increase coverage quickly

– Focus on a single delivery models for quick results

Scaling up and beyond

• Longer term thinking

• Reflect the diversity:

– Epidemiology

– Socio-economic settings

– Health systems

• Grounded/centred where the problem is

• Locus: local rather than global

Global conformity

� Heightened advocacy

� Increasing pressure

� 2010 coverage targets

Local diversity

Single solutions to delivery

Blunt, short-term instrum

ent

Range of delivery models

� Epidemiology

� Socio-economic settings

� Health systems

Global progress

The Paradigm Shift: beyond burden, towards transmission