The World Bank Institute and Futures Group

in collaboration with
OHanlon Health Consulting, Tropical Health LLP, and
University of California at San Francisco

JANUARY 2014

MARKETS FOR HEALTH

Session 5
Sustaining Universal
Coverage with Insecticide
Treated Nets to Prevent
Malaria
Albert Kilian

The World Bank Institute

in collaboration with
OHanlon 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

Multichannel BCC

Family

Social Norms

Perceived
barriers &
benefits

Free

Need
Deman
d
Experience
of disease

At
cost

Subsidiz
ed
Access to
LLIN
Subsidiz
ed

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
Deman
d 100%
90%
80%
Households with at least 1 ITN

70%

Pull

Pull

60%
50%

Campai
gn

40%

Push

Pull

ANC

30%

Push

20%
10%
0%
0

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

MARKETS FOR HEALTH

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

U5
CC
UC
C

Phase 2: 2008-2014

MIS 2007

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

MARKETS FOR HEALTH

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

SOCIAL FUNDING
100%

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

SOCIAL FUNDING
100%

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

SOCIAL FUNDING
100%

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
Infrastructure

Providers S

Invest

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
Infrastructure

Providers S

Invest

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
Infrastructure

Providers S

Invest

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
Infrastructure

Providers S

Invest

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

MARKETS FOR HEALTH

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