The World Bank Institute and Futures Group in collaboration with O’Hanlon Health Consulting, Tropical Health LLP, and University of California at San Francisco

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

MARKETS FOR HEALTH

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

MARKETS FOR HEALTH

OVERVIEW

MALARIA PREVENTION WITH ITN

ITN IN TANZANIA 2008-2014

USING M4H TO REVISE STRATEGY

SUMMARY

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




SUMMARY

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

Mosquito netConventional

ITNLLIN

Insecticide Treated Nets

Long-lasting treatment kit

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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

NetCALC output

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

The Role of the Public Sector

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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

The Family at the Center

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Experience of disease

Perceived risk of

malaria

Perceived barriers & benefits

FamilyNeed

Demand

Multichannel BCCAccess to

LLIN

Public SectorCivil Society

Private SectorMarkets

SubsidizedAt cost

Free Subsidized

Social Norms

Source: Kilian A, Koenker H, NetWorks Project

Post-campaign Demand & Sustainability

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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

use

ho

lds

wit

h a

t le

ast

1 IT

N

Push

Push

Pull

CampaignANC

Demand

Pull

Pull

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

Conclusion

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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




SUMMARY

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The Tanzania CasePhase 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 CasePhase 2: 2008-2014

U5C

CUC

C

Private sector

Voucher Scheme

SNP (pilot)

MIS 2007 MIS 2011

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The Tanzania CaseCoverage and equity of ITN ownership and use

NationalAny ITN: 39%Access to ITN: 26%

NationalAny ITN: 91%Access to ITN: 75%

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The Tanzania CaseCoverage of ITN ownership and use in 2013

Schools +

Voucher scheme

Voucher scheme

Situation 2014 - Public

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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)

Situation 2014 – Net/ITN Market

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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

Way Forward

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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




SUMMARY

Vision for Markets

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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 forcesCampaign Unstructured Market

OPERATIONAL AUTONOMY

CUSTOMER COMPETITION

PRICE INFLUENCE

ENTRY BARRIERS

SOCIAL FUNDING

PERFORMANCE TENSION FOR/UNDER CONTRACTS

Administered Market

Very High 0

100% 0

No contracts No tension

0% 100%

0% 100%

PRICE INFLUENCE

SOCIAL FUNDING

ENTRY BARRIERS

Administered Market

Very High 0

100% 0


0% 100%

0% 100%




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Market forcesCampaign Unstructured MarketVoucher Scheme

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Market forcesCampaign Unstructured MarketDesirable LLIN market


PRICE INFLUENCE



ENTRY BARRIERS

Administered Market

Very High 0

100% 0


0% 100%

0% 100%

SOCIAL FUNDING

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Markets systems

R&D

Rules

Regulations

Standards Laws

Informal Rulesand Norms

S D

Information

Quality Assurance

Subsidy

Infrastructure

Purchase

Public-Private Dialogue

Providers LLIN Retail Consumers

RelatedServices

Invest

Public-private dialogue and commitment to malaria prevention remains the most critical factor

Involve also Business Coalition, Corporate Responsibility Programs

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Markets systems

R&D

Rules

Regulations

Standards Laws


S D

Information

Quality Assurance

Subsidy

Infrastructure

Purchase



RelatedServices

Invest

Potential structuring interventions to be explored

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

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Markets systems

R&D

Rules

Regulations

Standards Laws


S D

Information

Quality Assurance

Subsidy

Infrastructure

Purchase



RelatedServices

Invest

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


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Markets systems

R&D

Rules

Regulations

Standards Laws


S D

Information

Quality Assurance

Subsidy

Infrastructure

Purchase



RelatedServices

Invest

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


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OVERVIEW




SUMMARY

Summary

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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

Thank You

Documents

The World Bank Institute and Futures Group in collaboration with O’Hanlon Health Consulting, Tropical Health LLP, and University of California at San Francisco