Results from the NATNETS Programme National Malaria Control Programme Tanzania Presentation for RBM / WIN March Nick Brown, ITN Cell Team Leader, NMCP

NATNETS Programme Tanzania NATNETS ITN Cell in the National Malaria Control Programme (funded by Swiss Agency for Development & Cooperation) ITN Cell in the National Malaria Control Programme (funded by Swiss Agency for Development & Cooperation) Tanzania National Voucher Scheme (funded by GFATM Round 1) Tanzania National Voucher Scheme (funded by GFATM Round 1) SMARTNET Social Marketing Programme (funded by DFID/RNE) SMARTNET Social Marketing Programme (funded by DFID/RNE) A long-term multi-donor, multi-partner initiative to promote the national use of ITNs made up of three complementary interventions:

NATNETS Programme Tanzania Approach Establishing and promoting the ITN Public Private Partnership to ensure: Affordability Accessibility Acceptability

NATNETS Programme Tanzania Tanzanian National Voucher Scheme The Four Contracting Partners Logistics: Voucher printing, distribution, administration and redemption: MEDA Logistics: Voucher printing, distribution, administration and redemption: MEDA Training & Promotion: World Vision Tanzania / CARE Training & Promotion: World Vision Tanzania / CARE Monitoring & Evaluation: LSHTM / Ifakara HRDC Monitoring & Evaluation: LSHTM / Ifakara HRDC Audit: KPMG Audit: KPMG

NATNETS Programme Tanzania MEDA / Namitech District Medical Officers & RCH Clinics Pregnant Women Retailers Wholesalers Manufacturers Voucher Books Individual Vouchers Redeemed Vouchers The TNVS Voucher Flow Individual Vouchers Redeemed vouchers

NATNETS Programme Tanzania TNVS Voucher Value & Prices of Nets  Tzs 2,750 ($2.50 approx) Retail Net prices vary from Tzs. 3, ,450 depending on size of net and remoteness Retail Net prices vary from Tzs. 3, ,450 depending on size of net and remoteness All nets manufactured in Tanzania are bundled with an Insecticide Treatment Kit All nets manufactured in Tanzania are bundled with an Insecticide Treatment Kit Top Up paid by women varies from Tzs 750 – 1700 (average = 1,019) Top Up paid by women varies from Tzs 750 – 1700 (average = 1,019) Top Up price represents retailer’s margin Top Up price represents retailer’s margin Retailer can only exchange vouchers for more nets Retailer can only exchange vouchers for more nets

NATNETS Programme Tanzania Achievements of TNVS >1.27 million vouchers distributed to DMOs and clinics by the end of 2005 >1.27 million vouchers distributed to DMOs and clinics by the end of 2005 Hati Punguzo is now operational in all 21 Regions Hati Punguzo is now operational in all 21 Regions National Coverage (last remaining districts) will be achieved by early April 2006 National Coverage (last remaining districts) will be achieved by early April 2006

NATNETS Programme Tanzania Hati Punguzo vouchers issued to DMOs and clinics by 2005 year end

NATNETS Programme Tanzania Hati Punguzo Voucher Redemption Rates 414,878 vouchers redeemed by the year end 414,878 vouchers redeemed by the year end Currently >545,000 vouchers redeemed Currently >545,000 vouchers redeemed Voucher redemption rates exceeded the monthly target for the first time in December 2005 Voucher redemption rates exceeded the monthly target for the first time in December 2005

NATNETS Programme Tanzania Growth of the Commercial Sector stimulated by TNVS Four Tanzanian Net Manufacturers Four Tanzanian Net Manufacturers A-Z A-Z Sunflag Sunflag TMTL TMTL Motex Motex Wholesalers Wholesalers Retailers Retailers

NATNETS Programme Tanzania Growth of the Commercial Sector stimulated by TNVS ITNs are now widely available in remote rural areas due to growth of the retail sector ITNs are now widely available in remote rural areas due to growth of the retail sector 2,618 retailers involved by end December 2,618 retailers involved by end December 80% of these retailers are new to the ITN business 80% of these retailers are new to the ITN business

NATNETS Programme Tanzania Growth of Commercial ITN Sales and Re-Treatment Kits Sales of ITNS in 2005 reached 2.4 million, 34% higher than 2004 Sales of ITNS in 2005 reached 2.4 million, 34% higher than 2004 Sales of insecticide re-treatment kits (IRKs) > million, 44% higher than 2004 Sales of insecticide re-treatment kits (IRKs) > million, 44% higher than 2004

NATNETS Programme Tanzania Other Achievements of TNVS As a result of TNVS, clinics are reporting increased attendance and are seeing women earlier in their pregnancy As a result of TNVS, clinics are reporting increased attendance and are seeing women earlier in their pregnancy In launched districts awareness of Hati Punguzo ranges from 52% (household heads) to 71% (pregnant women leaving clinics) In launched districts awareness of Hati Punguzo ranges from 52% (household heads) to 71% (pregnant women leaving clinics)

NATNETS Programme Tanzania Bednet Coverage Estimates Pregnant Women (HH Surveys) These differences cannot only be attributed to the TNVS These differences cannot only be attributed to the TNVS Early launched districts were closer to Dar es Salaam and probably had higher coverage to start with Early launched districts were closer to Dar es Salaam and probably had higher coverage to start with Early and Middle launched districts had higher SES than late launched Early and Middle launched districts had higher SES than late launched

NATNETS Programme Tanzania Bednet Coverage Estimates Children <5 (HH Surveys) These differences cannot only be attributed to the TNVS These differences cannot only be attributed to the TNVS Early launched districts were closer to Dar es Salaam and may have had higher coverage to start with Early launched districts were closer to Dar es Salaam and may have had higher coverage to start with Early and Middle launched districts had higher SES than late launched Early and Middle launched districts had higher SES than late launched

NATNETS Programme Tanzania Bednet Coverage Estimates Pregnant Women (Exit Surveys) These differences cannot only be attributed to the TNVS These differences cannot only be attributed to the TNVS Early launched districts were closer to Dar es Salaam and may have had higher coverage to start with Early launched districts were closer to Dar es Salaam and may have had higher coverage to start with Early and Middle launched districts had higher SES than late launched Early and Middle launched districts had higher SES than late launched

NATNETS Programme Tanzania Bednet Coverage by Socio–Economic Status Currently Pregnant Women (from LSHTM/IHRDC HH Survey June-Aug 2005)

NATNETS Programme Tanzania Current & Future Bednet Coverage Estimates Since the household and exit surveys were conducted, a further 375,000 vouchers have been redeemed by pregnant women, representing 27% of the estimated PW population Since the household and exit surveys were conducted, a further 375,000 vouchers have been redeemed by pregnant women, representing 27% of the estimated PW population A further 375,000 vouchers are expected to be redeemed within the next four months, prior to the next round of M&E surveys A further 375,000 vouchers are expected to be redeemed within the next four months, prior to the next round of M&E surveys

NATNETS Programme Tanzania Issues Widespread shortages of ANC cards in many (40) districts means many women are being denied a voucher Widespread shortages of ANC cards in many (40) districts means many women are being denied a voucher GFATM Phase 2 Agreement Letter still unsigned, four months after commencement of Phase 2. GFATM Phase 2 Agreement Letter still unsigned, four months after commencement of Phase 2. Women in poorest socio- economic group (Q1) are >50% less likely to be given a voucher as the least poor group (Q5) Women in poorest socio- economic group (Q1) are >50% less likely to be given a voucher as the least poor group (Q5)

NATNETS Programme Tanzania TNVS Programme Costs Once nationwide coverage is achieved, million nets will purchased with vouchers per year Once nationwide coverage is achieved, million nets will purchased with vouchers per year Annual cost of Phase 2: $5.5 million Annual cost of Phase 2: $5.5 million Price per net delivered incl. subsidy, 2 re-treatment kits, logistics, training, promotion, audit and administration Price per net delivered incl. subsidy, 2 re-treatment kits, logistics, training, promotion, audit and administration = $ $4.96 each = $ $4.96 each Delivery cost (logistics, training, promotion, audit & admin): Delivery cost (logistics, training, promotion, audit & admin): =$ $1.97 per net

NATNETS Programme Tanzania Next Steps Advocacy and Retraining Programme to address the right of all pregnant women to receive vouchers (March/April) Advocacy and Retraining Programme to address the right of all pregnant women to receive vouchers (March/April) Introduction of KO Tab 123 (April onwards) Introduction of KO Tab 123 (April onwards) Feasibility study for transfer of factory pre-treatment technology to Tanzanian manufacturers (current) Feasibility study for transfer of factory pre-treatment technology to Tanzanian manufacturers (current) Additional subsidy for 200,000 Olyset™ nets Additional subsidy for 200,000 Olyset™ nets USAID/PMI Programme USAID/PMI Programme

NATNETS Programme Tanzania Expanding the TNVS USAID/PMI Programme 2006 Infant Voucher in 15 Regions Infant Voucher in 15 Regions Equity (“Safety Net”) Voucher in 12 Districts Equity (“Safety Net”) Voucher in 12 Districts Long Lasting Insecticide Treated Net (LLIN) Technology Transfer Long Lasting Insecticide Treated Net (LLIN) Technology Transfer

NATNETS Programme Tanzania TNVS Infant Voucher Delivered at 9 months with measles vaccination Delivered at 9 months with measles vaccination Value = Tzs 2750 (same as PW voucher) Value = Tzs 2750 (same as PW voucher) Funding in Year 1 to reach 15 Regions Funding in Year 1 to reach 15 Regions Selection Criteria Selection Criteria Infant Mortality Infant Mortality Excluding regions and districts that have recently received free nets Excluding regions and districts that have recently received free nets

NATNETS Programme Tanzania TNVS Equity Voucher Targeted at the most needy Targeted at the most needy Selection and Delivery Mechanism to be determined Selection and Delivery Mechanism to be determined Probably a top-up voucher over and above the PW & Infant Voucher Probably a top-up voucher over and above the PW & Infant Voucher Value to be determined (range Tsh ) if a top up Value to be determined (range Tsh ) if a top up Funding in Year 1 to reach 12 districts Funding in Year 1 to reach 12 districts District Selection by Poverty Indicator & Infant Mortality District Selection by Poverty Indicator & Infant Mortality

NATNETS Programme Tanzania Next Steps - Medium Term ( Subject to full approval of PMI programme) Expansion of Infant Voucher from 15 to all 21 regions (from 2007) Expansion of Infant Voucher from 15 to all 21 regions (from 2007) Introduction of <5 voucher (from 2007) Introduction of <5 voucher (from 2007) Expansion of Equity Voucher ( ) Expansion of Equity Voucher ( )

NATNETS Programme Tanzania Acknowledgements Our donors Our donors GFATM GFATM SDC SDC DCI DCI DFID/RNE DFID/RNE Swiss Tropical Institute Swiss Tropical Institute Our Contracting Partners Our Contracting Partners MEDA MEDA World Vision / CARE World Vision / CARE LSHTM / IHRDC LSHTM / IHRDC PSI PSI KPMG KPMG The Tanzanian Net Manufacturers The Tanzanian Net Manufacturers Karen Kramer Karen Kramer