1. 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

2. 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

3. MARKETS FOR HEALTH OVERVIEW MALARIA PREVENTION WITH ITN ITN IN TANZANIA 2008-2014 USING M4H TO REVISE STRATEGY SUMMARY

4. 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 MARKETS FOR HEALTH

5. OVERVIEW MALARIA PREVENTION WITH ITN ITN IN TANZANIA 2008-2014 USING M4H TO REVISE STRATEGY SUMMARY

6. 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 net Conventional ITN LLIN Insecticide Treated Nets Long-lasting treatment kit MARKETS FOR HEALTH

7. 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) MARKETS FOR HEALTH

8. 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 MARKETS FOR HEALTH

9. 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

10. The Role of the Public Sector MARKETS FOR HEALTH  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

11. The Family at the Center MARKETS FOR HEALTH Experience of disease Perceived risk of malaria Perceived barriers & benefits Family Need Demand Multichannel BCC Access to LLIN Public Sector Civil Society Private Sector Markets Subsidized At cost Free Subsidized Social Norms Source: Kilian A, Koenker H, NetWorks Project

12. Post-campaign Demand & Sustainability MARKETS FOR HEALTH Push Pull Campaign ANC Demand 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

13. Conclusion MARKETS FOR HEALTH  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

14. MARKETS FOR HEALTH OVERVIEW MALARIA PREVENTION WITH ITN ITN IN TANZANIA 2008-2014 USING M4H TO REVISE STRATEGY SUMMARY

15. 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  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

16. MARKETS FOR HEALTH The Tanzania Case Phase 2: 2008-2014 U5CC UCC Private sector Voucher Scheme SNP (pilot) MIS 2007MIS 2011

17. MARKETS FOR HEALTH 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%

18. MARKETS FOR HEALTH The Tanzania Case Coverage of ITN ownership and use in 2013 Schools + Voucher scheme

19. Situation 2014 - Public MARKETS FOR HEALTH  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)

20. Situation 2014 – Net/ITN Market MARKETS FOR HEALTH  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

21. Way Forward MARKETS FOR HEALTH  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

22. MARKETS FOR HEALTH OVERVIEW MALARIA PREVENTION WITH ITN ITN IN TANZANIA 2008-2014 USING M4H TO REVISE STRATEGY SUMMARY

23. Vision for Markets MARKETS FOR HEALTH  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

24. MARKETS FOR HEALTH Market forces Campaign Unstructured Market OPERATIONAL AUTONOMY CUSTOMER COMPETITION PRICE INFLUENCE ENTRY BARRIERS SOCIAL FUNDING PERFORMANCE TENSION FOR/UNDER CONTRACTS AdministeredMarket Very High0 100%0 No contractsNo tension 0%100% 0%100%

25. PRICE INFLUENCE SOCIAL FUNDING ENTRY BARRIERS AdministeredMarket Very High0 100%0 No contractsNo tension 0%100% 0%100% CUSTOMER COMPETITION OPERATIONAL AUTONOMY PERFORMANCE TENSION FOR/UNDER CONTRACTS MARKETS FOR HEALTH Market forces Campaign Unstructured Market Voucher Scheme

26. MARKETS FOR HEALTH Market forces Campaign Unstructured Market Desirable LLIN market PERFORMANCE TENSION FOR/UNDER CONTRACTS PRICE INFLUENCE OPERATIONAL AUTONOMY CUSTOMER COMPETITION ENTRY BARRIERS AdministeredMarket Very High0 100%0 No contractsNo tension 0%100% 0%100% SOCIAL FUNDING

27. MARKETS FOR HEALTH Markets systems R&D Rules Regulations Standards Laws Informal Rules and Norms S D Information Quality Assurance Subsidy Infrastructure Purchase Public-Private Dialogue Providers LLIN Retail Consumers Related Services Invest  Public-private dialogue and commitment to malaria prevention remains the most critical factor  Involve also Business Coalition, Corporate Responsibility Programs

28. MARKETS FOR HEALTH Markets systems R&D Rules Regulations Standards Laws Informal Rules and Norms S D Information Quality Assurance Subsidy Infrastructure Purchase Public-Private Dialogue Providers LLIN Retail Consumers Related Services 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

29. MARKETS FOR HEALTH Markets systems R&D Rules Regulations Standards Laws Informal Rules and Norms S D Information Quality Assurance Subsidy Infrastructure Purchase Public-Private Dialogue Providers LLIN Retail Consumers Related Services 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 Potential structuring interventions to be explored

30. MARKETS FOR HEALTH Markets systems R&D Rules Regulations Standards Laws Informal Rules and Norms S D Information Quality Assurance Subsidy Infrastructure Purchase Public-Private Dialogue Providers LLIN Retail Consumers Related Services 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 Potential structuring interventions to be explored

31. MARKETS FOR HEALTH OVERVIEW MALARIA PREVENTION WITH ITN ITN IN TANZANIA 2008-2013 USING M4H TO REVISE STRATEGY SUMMARY

32. Summary MARKETS FOR HEALTH  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

33. Thank You