Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
National ITN Implementation
Plan
Achieving nation-wide ITN usage in the
United Republic of Tanzania
National Malaria Control Programme
Tanzania
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Estimated Population at Risk of
Malaria – Tanzanian - 2000
• Population
– Total
– At risk of malaria
33.8 million (100%)
31.6 million (93.7%)
• Population at risk where transmission lasts:
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–
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>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%)
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Tanzania’s Burden of Disease
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
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
ITN Effectiveness
• 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
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
ITN Effectiveness
• KINET evidence – for treated net users:
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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
Tanzania
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Why ITNs in Tanzania ?
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High need
Strong research-based effectiveness evidence
Cost-effectiveness advantage
Public sector becoming more responsive
Energetic private sector
Expanding district level involvement
NGOs engaged and willing
Renewed commitment from donor partners
Evidence of increased household expenditure
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
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
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 marketing
• Commercial sector is already successfully
marketing Nets and treatment kits
• Local commercial distribution is more efficient
than projects (mark-up $2-$4)
• Must use public funds in the most effective way
• So - Need to target resources to those most at risk
without reducing commercial sales
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Public Sector ITN Distribution ?
• Attractive opportunity – promote and sell
nets at clinics
• Revolving funds at clinic / district level
hard to administer – large losses reported
• Temptation to take excess profit so cost not
reduced
• Public Health facilities is not the best option
for delivery of ITNs
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
urban
• Combined production of the three
net manufacturing companies – 4
million nets per annum
• Key partnerships with insecticide
producers – kit price now $ 0.35
• Retail price of nets: $2.6 – $3.6
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Enabling Factors
• Establishment of ITN Multisectoral Task
Force
• Strong local research base
• Strong and growing manufacturing sector
• Donors prepared to invest and encourage
manufacturers through demand creation
• Dynamic, committed, social marketing team
• Committed individuals supporting
development of plan – NMCP, MoH, Researchers,
Private sector, NGOs, donors.
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Enabling Factors
• Removal of taxes and tariffs on both nets
insecticides
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Challenges
• Advocacy – reaching a critical mass
• Sustainability of the momentum which has
substantial donor support
• Concurrent activity when human resources
are over stretched
• Net use in rural areas is still strongly
seasonal, yet malaria transmission is all year
round
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Challenges
• Reaching those who truly may not be able
to afford a net
• Balancing public health gain and private
cost
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
So
The way forward
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Strategic Approach
• Demand creation - Government / Donor funded and
contracted out
• Production, distribution, sales - Private sector
• Regulatory coordination - Government (NMCP) and
regulatory instruments of the govt.
• Monitoring and Evaluation / Research - Government
(NMCP) coordinated / contracted out / research partners
• ITN Steering Committee - Multi-stakeholder
• Coordination and Management – NMCP based
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Implementation Plan
• ITN Steering Committee formed from Task
Force
– Responsible to MoH
• CMO and NMCP Manager on Steering
Committee
• Implementation Team a ‘cell’ within NMCP
• Implementation Team Leader reports to
Steering Committee
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Implementation Team Role
• Advocacy / Negotiation
• Management of process
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Demand creation co-ordination / contracting
Research co-ordination / contracting
Management of Voucher scheme
Regulatory / Revenue lobbying
• Financial management
• Technical advice / support to Districts
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Public / Private partnership
• Implementation Team role to:
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Co-ordinate
Facilitate
Negotiate
Broker agreement
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Role of Social Marketing
• Concentrates 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.
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Evolving Partner Contributions
START
Production
PUBLIC
SECTOR
Distribution
Consumer
information
PRIVATE
Distribution
Create enabling
environment
Demand
Creation
Household / community
demand creation
Research
Partners
Equity &
Vulnerable groups
Distribution
NGOs
Donor
Partners
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Desired Framework for Partners
PUBLIC
SECTOR
PRIVATE
SECTOR
National generic demand
creation
National co-ordination
Consumer protection
- regulatory issues
Create enabling
environment
Consumer
information
Brand specific demand creation
Supply & Sales
Demand
Creation
Household / community
demand creation
Product
development
Distribution
Distribution
Equity &
Vulnerable groups
DONOR
PARTNERS
NGOs
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
RESEARCH
PARTNERS
Core activities of Social Marketing within
evolution of ITN Implementation Plan
70%
2007
Market mature, NMCP subsumes role of
Implementation Team. ITN projects, except
equity based, phased out. Evaluation,
Social Marketing
monitoring and essential promotion MoH
(promotion)
funded.
2005
KINET
2002
Market Maturing
Implementation Team
Operational: Advocacy,
technical support,
Contracting of
activities to Private
sector.
and
other
equity
based
projects Implementation
team funded
Market
Forming
Social
Marketing
(promotion and
distribution)
50%
Coverage
10%
Social Marketing
(promotion, distribution
and advocacy)
2000
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
The availability of Nets and
Insecticides in the country
• Maximum choice of ITN commodities
• Facilitated co-operation between TPRI /
TBS and net/insecticide manufacturers
• Nets bundled with Insecticide
• Agreement reached that all nets sold will
be with insecticide (c.f. iodised salt)
• Insecticide kits
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
GFATM proposal for malaria
• Equitable targeting to highest risk groups
– Pregnant women and infants
• Voucher system
– linked to uptake of essential health interventions
• antenatal clinic attendance, EPI uptake
– high value to encourage uptake
– MCH staff distribute, Banks cash voucher
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Vouchers
• benefits
– 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
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Vouchers
• risks
– Fraud, high value  high risk
– Retailer refusal to honour voucher
– Banks refusal to co-operate
– Retailers don’t get money
– Who uses the ITN in the home ?
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Subsidy – Research Gaps
• Market research - who truly still needs subsidy
• Commercial sector slow to engage in the process
(voucher scheme)
• Extent of Black market (leakage of voucher)
• Definition of criteria for access ?
• Monitoring and Control systems ?
• Audit
• Cost ? Risks ?
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Accelerated Access
• Requires
– Massive effort
– Significant extra resources
• GFATM approval
• Bilateral support is time limited
– New ways of working
• Contracting out
• Private sector skills  public sector
• Stakeholder co-ordination
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
District Activities
• Persistent behaviour change requires:
– Integrated district / community activities that
encourage adoption of new ideas
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
BUT - Who makes the choices ?
• Community
empowerment
• Changing behaviour
• Empowering women
• Income generation
• Fair pricing
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
Consumers
• Prioritising health
needs – knowledge
based
• Local availability of
low cost ITN supplies
• Economic gains from
reduced malaria
burden
• Increased human
capital
• Maintain long term
view
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002
AHSANTE SANA
Tanzania ITN Implementation Plan – RBM/IMCI Harare 2002