1. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002

2. National ITN Implementation Plan Achieving nation-wide ITN usage in the United Republic of Tanzania National Malaria Control Programme Tanzania

3. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Estimated Population at Risk of Malaria – Tanzanian - 2000 Population – –Total33.8 million (100%) – –At risk of malaria31.6 million (93.7%) Population at risk where transmission lasts: – –>6 months (stable, perennial) 14.1 m (42%) – –4-6 months (stable, seasonal) 11.3 m (33%) – –1-3 months ( strongly seasonal/epidemic) 2.6 m (8%) – –<1 month (epidemic/no malaria in avg.Year) 5.8m (17%)

4. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Malaria: Estimated 16 million malaria cases per year Consumes 119 million US $ per year (3.4%GDP) Most deaths in under-five children and pregnant women Under 5 year child deaths estimated at 161,000 (per 1000 live births) per year of which 39,000 due to malaria Tanzanias Burden of Disease

5. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 ITN Effectiveness Results of large scale ITN trials in Africa:Results of large scale ITN trials in Africa: –Overall 20% reduction in all cause child mortality –Overall 50% reduction in malarial illness –Effective at all levels of transmission –5.6 deaths averted per 1000 children per year –Despite < 70% compliance

6. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 ITN Effectiveness KINET evidence – for treated net users:KINET evidence – for treated net users: –Childhood (1 month – 4 years) protective efficacy of 27% –63% less parasitaemia –63% less anaemia –Children generally healthier and grow better –Protected pregnant women 12% less anaemia –Despite low re-treatment rates in an area of perennial transmission with very high biting rates For children under 5 alone this could translate into more than 30,000 deaths averted per year in TanzaniaFor children under 5 alone this could translate into more than 30,000 deaths averted per year in Tanzania

7. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Why ITNs in Tanzania ? High needHigh need Strong research-based effectiveness evidenceStrong research-based effectiveness evidence Cost-effectiveness advantageCost-effectiveness advantage Public sector becoming more responsivePublic sector becoming more responsive Energetic private sectorEnergetic private sector Expanding district level involvementExpanding district level involvement NGOs engaged and willingNGOs engaged and willing Renewed commitment from donor partnersRenewed commitment from donor partners Evidence of increased household expenditureEvidence of increased household expenditure

8. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Where do we want to go ? High utilization of ITNs through more equitable access What does this mean for Tanzania ? Present coverage – – –<50% of children sleep under any net – –Coverage of ITNs is greater, in project areas (up to 30%) when compared to non project areas – –Areas with ITN projects, 13 – 28 % ITN coverage – –Overall net usage 80% in some towns, 50% in rural areas

9. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Targets By 2007: at least 60 % of children under 5 years of age and pregnant women will be sleeping under an appropriately treated mosquito net

10. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 How to meet Public Health Need? Donors and Government unable to meet costs of project type social marketingDonors and Government unable to meet costs of project type social marketing Commercial sector is already successfully marketing Nets and treatment kitsCommercial sector is already successfully marketing Nets and treatment kits Local commercial distribution is more efficient than projects (mark-up $2-$4)Local commercial distribution is more efficient than projects (mark-up $2-$4) Must use public funds in the most effective wayMust use public funds in the most effective way So - Need to target resources to those most at risk without reducing commercial salesSo - Need to target resources to those most at risk without reducing commercial sales

11. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Public Sector ITN Distribution ? Attractive opportunity – promote and sell nets at clinicsAttractive opportunity – promote and sell nets at clinics Revolving funds at clinic / district level hard to administer – large losses reportedRevolving funds at clinic / district level hard to administer – large losses reported Temptation to take excess profit so cost not reducedTemptation to take excess profit so cost not reduced Public Health facilities is not the best option for delivery of ITNsPublic Health facilities is not the best option for delivery of ITNs

12. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Commercial Sector involvement Sales grown to more than 1.5 million per year through existing commercial networks – mainly urbanSales grown to more than 1.5 million per year through existing commercial networks – mainly urban Combined production of the three net manufacturing companies – 4 million nets per annumCombined production of the three net manufacturing companies – 4 million nets per annum Key partnerships with insecticide producers – kit price now $ 0.35Key partnerships with insecticide producers – kit price now $ 0.35 Retail price of nets: $2.6 – $3.6Retail price of nets: $2.6 – $3.6

13. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Enabling Factors Establishment of ITN Multisectoral Task ForceEstablishment of ITN Multisectoral Task Force Strong local research baseStrong local research base Strong and growing manufacturing sectorStrong and growing manufacturing sector Donors prepared to invest and encourage manufacturers through demand creationDonors prepared to invest and encourage manufacturers through demand creation Dynamic, committed, social marketing teamDynamic, committed, social marketing team Committed individuals supporting development of plan – NMCP, MoH, Researchers, Private sector, NGOs, donors.Committed individuals supporting development of plan – NMCP, MoH, Researchers, Private sector, NGOs, donors.

14. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Enabling Factors Removal of taxes and tariffs on both nets insecticidesRemoval of taxes and tariffs on both nets insecticides

15. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Challenges Advocacy – reaching a critical massAdvocacy – reaching a critical mass Sustainability of the momentum which has substantial donor supportSustainability of the momentum which has substantial donor support Concurrent activity when human resources are over stretchedConcurrent activity when human resources are over stretched Net use in rural areas is still strongly seasonal, yet malaria transmission is all year roundNet use in rural areas is still strongly seasonal, yet malaria transmission is all year round

16. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Challenges Reaching those who truly may not be able to afford a netReaching those who truly may not be able to afford a net Balancing public health gain and private costBalancing public health gain and private cost

17. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 So The way forward

18. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Strategic Approach Demand creation - Government / Donor funded and contracted outDemand creation - Government / Donor funded and contracted out Production, distribution, sales - Private sectorProduction, distribution, sales - Private sector Regulatory coordination - Government (NMCP) and regulatory instruments of the govt.Regulatory coordination - Government (NMCP) and regulatory instruments of the govt. Monitoring and Evaluation / Research - Government (NMCP) coordinated / contracted out / research partnersMonitoring and Evaluation / Research - Government (NMCP) coordinated / contracted out / research partners ITN Steering Committee - Multi-stakeholderITN Steering Committee - Multi-stakeholder Coordination and Management – NMCP basedCoordination and Management – NMCP based

19. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Implementation Plan ITN Steering Committee formed from Task ForceITN Steering Committee formed from Task Force –Responsible to MoH CMO and NMCP Manager on Steering CommitteeCMO and NMCP Manager on Steering Committee Implementation Team a cell within NMCPImplementation Team a cell within NMCP Implementation Team Leader reports to Steering CommitteeImplementation Team Leader reports to Steering Committee

20. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Implementation Team Role Advocacy / NegotiationAdvocacy / Negotiation Management of processManagement of process –Demand creation co-ordination / contracting –Research co-ordination / contracting –Management of Voucher scheme –Regulatory / Revenue lobbying Financial managementFinancial management Technical advice / support to DistrictsTechnical advice / support to Districts

21. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Public / Private partnership Implementation Team role to:Implementation Team role to: –Co-ordinate –Facilitate –Negotiate –Broker agreement

22. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Role of Social Marketing Concentrates on commercial alliances to increase net availability in rural areasConcentrates on commercial alliances to increase net availability in rural areas Promotes a national brand of Insecticide (Ngao) for a variety of different net treatments – consumer confidence and recognition, while encouraging competition to reduce cost.Promotes a national brand of Insecticide (Ngao) for a variety of different net treatments – consumer confidence and recognition, while encouraging competition to reduce cost.

23. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Evolving Partner Contributions PRIVATE PUBLIC SECTOR Demand Creation Distribution NGOs Household / community demand creation Equity & Vulnerable groups Create enabling environment Distribution Production Consumer information Research Partners Donor Partners START

24. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Consumer information PRIVATE SECTOR PUBLIC SECTOR NGOs National generic demand creation Brand specific demand creation Household / community demand creation Supply & Sales Product development Equity & Vulnerable groups National co-ordination Consumer protection - regulatory issues Distribution Create enabling environment Desired Framework for Partners DONOR PARTNERS Demand Creation RESEARCH PARTNERS

25. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 2000 2002 2005 2007 Market mature, NMCP subsumes role of Implementation Team. ITN projects, except equity based, phased out. Evaluation, monitoring and essential promotion MoH funded. Social Marketing (promotion) Social Marketing (promotion and distribution) Social Marketing (promotion, distribution and advocacy) KINET and other equity based projects Market Maturing Implementation Team Operational: Advocacy, technical support, Contracting of activities to Private sector. Implementation team funded Market Forming Core activities of Social Marketing within evolution of ITN Implementation Plan 10% 50% 70% Coverage

26. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 The availability of Nets and Insecticides in the country Maximum choice of ITN commoditiesMaximum choice of ITN commodities Facilitated co-operation between TPRI / TBS and net/insecticide manufacturersFacilitated co-operation between TPRI / TBS and net/insecticide manufacturers Nets bundled with InsecticideNets bundled with Insecticide Agreement reached that all nets sold will be with insecticide (c.f. iodised salt)Agreement reached that all nets sold will be with insecticide (c.f. iodised salt) Insecticide kitsInsecticide kits

27. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 GFATM proposal for malaria Equitable targeting to highest risk groupsEquitable targeting to highest risk groups –Pregnant women and infants Voucher systemVoucher system –linked to uptake of essential health interventions antenatal clinic attendance, EPI uptakeantenatal clinic attendance, EPI uptake –high value to encourage uptake –MCH staff distribute, Banks cash voucher

28. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Vouchers benefitsbenefits –encourages private sector sales and rural penetration –will not destabilise market –readily identifiable qualification (pregnancy) –less administration for health staff –could pull antenatal and EPI coverage up

29. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Vouchers risksrisks –Fraud, high value high risk –Retailer refusal to honour voucher –Banks refusal to co-operate –Retailers dont get money –Who uses the ITN in the home ?

30. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Subsidy – Research Gaps Market research - who truly still needs subsidyMarket research - who truly still needs subsidy Commercial sector slow to engage in the process (voucher scheme)Commercial sector slow to engage in the process (voucher scheme) Extent of Black market (leakage of voucher)Extent of Black market (leakage of voucher) Definition of criteria for access ?Definition of criteria for access ? Monitoring and Control systems ?Monitoring and Control systems ? AuditAudit Cost ? Risks ?Cost ? Risks ?

31. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Accelerated Access RequiresRequires –Massive effort –Significant extra resources GFATM approvalGFATM approval Bilateral support is time limitedBilateral support is time limited –New ways of working Contracting outContracting out Private sector skills public sectorPrivate sector skills public sector Stakeholder co-ordinationStakeholder co-ordination

32. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 District Activities Persistent behaviour change requires:Persistent behaviour change requires: –Integrated district / community activities that encourage adoption of new ideas

33. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 BUT - Who makes the choices ? Community empowermentCommunity empowerment Changing behaviourChanging behaviour Empowering womenEmpowering women Income generationIncome generation Fair pricingFair pricing

34. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 Prioritising health needs – knowledge basedPrioritising health needs – knowledge based Local availability of low cost ITN suppliesLocal availability of low cost ITN supplies Economic gains from reduced malaria burdenEconomic gains from reduced malaria burden Increased human capitalIncreased human capital Maintain long term viewMaintain long term view Consumers

35. Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002 AHSANTE SANA