This document discusses strategies for achieving universal access to effective malaria prevention and treatment. It argues that a mixed model approach is needed, using both public and private sector engagement. For prevention, long-lasting insecticidal nets (LLINs) distributed through both mass campaigns and routine channels can rapidly increase and sustain high coverage levels. Price support for LLINs sold in the commercial sector can help increase access, competition, and market sustainability over the long term. The goal is for vulnerable groups to be protected through both public and private health services.
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Beyond Scaling Up: Universal Access to Effective Malaria Prevention and Treatment. How do we get there?
1. Beyond Scaling Up
Universal Access to Effective
Malaria Prevention and Treatment:
how do we get there?
Sunil Mehra
Executive Director, Malaria Consortium
with contributions from
Dr. Albert Kilian, Dr. Sylvia Meek, Dr. Graham Root,
and Caroline Vanderick
2. MALARIA - Introduction
Malaria control rests on two major pillars
Case Prevention
Management
Treatment LLIN
Parasite Vector
Environment
IPTp IRS
Host
Environmetal
IPTi Management
Within the prevention arm Long-Lasting Insecticidal Nets (LLIN)
form the most important intervention in sub-Saharan Africa
3. Prevention with LLIN
For many years the RBM Working Group on ITN (now Vector
Control WG) has suggested a mixed model approach to scaling
up ITN
However, actual implementation did not take off due to lack of
donor commitment 2003-05
2003
Unsubsidized commercial expansion for sustainability
Short term subsidies to encourage ITN market growth
Long term targeted subsidies for most vulnerable
Domestic funding
Donor funding
2010
Time
5. Our Vision
Vulnerable groups are protected with LLINs and access
effective treatment through public and private channels.
Informed households, including poor, demand for and can
obtain free or affordable LLINs
Increased demand encourages many suppliers,
competition keeps prices low; and rural and community-
based distribution systems expand.
The burden of malaria declines especially
amongst the poor.
7. Public Health Private Markets
Aiming for sustained total coverage
Each sector has unique strengths
All contribute to public health, none alone can achieve total coverage
Public Sector
Civil Society Commercial Sector
Improving delivery
of health services, Focus on the poor Improving access
setting policies, and marginalised through competition
stewardship
Public health private markets extends the potential of each sector
through an inclusive and pluralistic approach
8. Balance of components
Creation of sustainable demand & supply across all populations
Public and civil society
Commercial sector support
sector component
Ensures equity and targeting
4.4 million free LLINs through
campaigns Mass market response and
Achieves rapid results
SMoH supported to distribute lower pricing leads to long-term
10 million subsidised LLINs
5 million LLINs through ANC
Helps open up mass market sustainability
through commercial sector
demand of care improved in
Quality 9.5 million subsidised <5yrs
6,500 health facilities ACTs at 10 cents each
30 million doses of SP for IPT
provided
Key strategy: demand creation and a blended
distribution system for sustained and equitable
impact
10. The Evidence from Kenya
Reviewed three different distribution models
1. Traditional social marketing model by PSI
2. Health facility based distribution of subsidised nets ($0.70)
3. Campaign distribution of free ITNs to under-fives
Two key findings
1. Only campaigns able to reach high coverage levels quickly
2. Campaigns can reach the poor
DFID five year support to ITN social marketing in Kenya
1. Had limited impact on coverage / ‘access’
2. Impacted negatively on the real commercial sector
11. MCP Approach to Coverage
• Kenya data confirms a key element of the MCP
approach – campaigns are necessary
• MCP recognises that a mixed model is essential to not
only rapidly increase coverage but also to sustain it
• Rapid increase
– Free campaigns
• Sustain high coverage
– Routine free distribution through ANC and health facilities
– Improved access to LLINs through the commercial sector at
an affordable price
12. Malaria Consortium
Sustaining LLIN/ITN Targets Model
• Developed by Malaria Consortium M&E and Research
Department
• Model estimates required inputs to attain and sustain
coverage levels for LLIN/ITNs
• Model validated against real data from our Uganda
and Mozambique programmes
• Currently being used by RBM partners
• RBM adopted our model to forecast LLIN/ITN needs
across Africa
13. Malaria Consortium Sustaining LLIN Targets Model
Dynamic Loss Function
100%
Proportion of nets still in use 90%
Polyethylene
80%
Polyester
70%
60%
50%
40%
30%
20%
10%
0%
0 2 4 6 8 10 12 14 16 18
Tim e in years
14. Nigeria: total expected net output in 12
project states
4,500,000
4,000,000
3,500,000
3,000,000
Net output
campaign
2,500,000
routine
LLIN subsidy
2,000,000
unsubsidized
1,500,000
1,000,000
500,000
0
1 2 3 4 5
Year
15. Nigeria – 12 project states
Campaigns children under 5
10,000,000 100.0%
9,000,000 90.0%
Proportion of hh with at least one net in %
8,000,000 80.0%
Number of nets distributed
7,000,000 70.0%
6,000,000 60.0%
total net output
5,000,000 50.0% commercial
ITN coverage
4,000,000 40.0%
3,000,000 30.0%
2,000,000 20.0%
1,000,000 10.0%
0 0.0%
0 1 2 3 4 5
Year
16. Nigeria – 12 project states
Campaigns children under 5 + ANC
10,000,000 100.0%
9,000,000 90.0%
Proportion of hh with at least one net in %
8,000,000 80.0%
Number of nets distributed
7,000,000 70.0%
6,000,000 60.0%
total net output
5,000,000 50.0% commercial
ITN coverage
4,000,000 40.0%
3,000,000 30.0%
2,000,000 20.0%
1,000,000 10.0%
0 0.0%
0 1 2 3 4 5
Year
17. Nigeria – 12 project states
Campaigns children under 5 + ANC + commercial subsidy
10,000,000 100.0%
9,000,000 90.0%
Proportion of hh with at least one net in %
8,000,000 80.0%
Number of nets distributed
7,000,000 70.0%
6,000,000 60.0%
total net output
5,000,000 50.0% commercial
ITN coverage
4,000,000 40.0%
3,000,000 30.0%
2,000,000 20.0%
1,000,000 10.0%
0 0.0%
0 1 2 3 4 5
Year
18. Nigeria – 12 project states
Campaigns children under 5 + ANC + commercial subsidy + unsubsidized
10,000,000 100.0%
9,000,000 90.0%
Proportion of hh with at least one net in %
8,000,000 80.0%
Number of nets distributed
7,000,000 70.0%
6,000,000 60.0%
total net output
5,000,000 50.0% commercial
ITN coverage
4,000,000 40.0%
3,000,000 30.0%
2,000,000 20.0%
1,000,000 10.0%
0 0.0%
0 1 2 3 4 5
Year
25. The Evidence from Mozambique
100
Cumulative % of households with intervention by wealth quintile
Equity line
90 Concentration Curve Com LLIN
Pub LLIN
80 SM LLIN
70
60
Equity of LLIN by
Distribution Mechanism
50
40 Concentration Index
30
Public -0.11
20
Commercial +0.11
10
Social Marketing +0.42
0
0 10 20 30 40 50 60 70 80 90 100
Cumulative % of all households by wealth quitile
26. Reaching the Poor - Prevention
• Kenya evidence
– Shows free campaigns are pro-poor
– Shows inequity of single-branded social marketing
• Mozambique evidence
– Shows free ANC and campaign distributions are
pro-poor
– Show reasonable equity for commercial sector
– Shows inequity of single-branded social marketing
27. The reach of our partnership
Distribution Networks
Sprin
l– gfield
g l oba exten s/Af
P atem wide sive c cott –
n rk farme ot
natio n netwo rs net ton
tio work
dis tribu
cal
aceuti CHAN MediPharm –
Pharm ers – well Depots serving all six C.Zard – over 150
ur
ma nufact networks zones retailers country-w
ide
red
structu
Har
exten vestfield – Rosies Textile
s–
sive d etwork
netwo istribu
tion distribution n
rk in s d Kano
outh for SE, SW an
29. Price Support
• Price support is channelled through the commercial
sector
• Implementing agency does not retain the price
support/subsidy
• Pioneering approach: done in Uganda and
Mozambique by MC
• Price support aims to:
– Reduce the price of quality/qualified LLINs
– Increase competition and choice
– Extend the market reach
– Support the development of a viable and expanding market
30. Price support – does it work?
• Malaria Consortium experience in
Mozambique and Uganda :
– Increased commercial sector sales of LLINs
– Increased number of brands on market
– Reduced retail price of LLINs to compete with
conventional untreated (and often poor quality)
nets
– Commercial sector sales rose at a time of mass
free LLIN distributions
31. MCP commercial partners’ ITN sales,
Mozambique
340,000
320,000
300,000
280,000 institutional
260,000 retail
Cumulative ITN sales
240,000
220,000
200,000
180,000
160,000
140,000
120,000
100,000
80,000
60,000
40,000
20,000
0
MAY
MAY
JAN
MAR
APR
JAN
MAR
APR
AUG
AUG
JUL
OCT
JUL
OCT
NOV
SEP
NOV
SEP
NOV
DEC
JUN
DEC
JUN
DEC
FEB
FEB
2005 2006 2007
32. Examples of commercial sector development
100.0% 5,000,000
public and civil society
social marketing
90.0% commercial partners 4,500,000
estimated informal market
% LLIN
80.0% 4,000,000
70.0% 3,500,000
Proportion of nets LLIN
U
Total number of nets
60.0% 3,000,000
g
a 50.0% 2,500,000
n
d 40.0% 2,000,000
a
30.0% 1,500,000
20.0% 1,000,000
10.0% 500,000
0.0% 0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
33. Rapid Scale-up
Since 2005 increasing investments and since
2008 good progress in many countries
Based on modelling and practical experience
clear indication that only mass campaign style
distributions can achieve rapid scale-up
towards universal coverage
34. Limitations of Campaigns
However, loss of nets through “wear and tear” and other behavioural
factors starts early
Model Field data
100% 100% 100
90% 90% 90
80% 80% 80
Households with at least 1 ITN
70% 70% 70
60% 60% 60
50% 50% 50
40% 40% 40 Togo
30% 30% 30 Sofala - Moz
20% 20% 20 Manica - Moz
10% 10%
10 Law ra - Ghana
0% 0%
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 0 1 2 3 4 5 6 7 8
Years Years
35. Limitations of Campaigns
Even repeated campaigns can not sustain high levels
of coverage in an continuous fashion
100% 100%
90% 90%
80% 80%
Households with at least 1 ITN
70% 70%
60% 60%
50% 50%
40% 40%
30% 30%
20% 20%
10% 10%
0% 0%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Years
36. Need for continuous distributions
Distributions are needed that supply LLIN to
target groups and/or customers in a
continuous manner over long periods of time
To reach new families
To replace torn, lost or destroyed nets
To fill gaps in family demand for nets not covered
by campaign distributions
To satisfy demand for choice (size, shape, colour
of nets)
37. Channels for continuous distributions
Primary distribution mechanisms are
Routine health services (ANC/EPI)
Commercial retail market
Unsubsidized
Subsidized through “total market approach”
Additionally and/or in places were neither health
services nor the market can reach the population
alternatives must be developed
Through community based approaches
Schools
Religious institutions
38. Sustaining high coverage
Modelling suggest that this mixed approach will sustain
high coverage (emerging support from data)
100% 100%
90% 90%
80% 80%
Households with at least 1 ITN
70% 70%
ANC 85% & 20% hh
60% ANC 85% & 40% hh 60%
50% 50%
40% 40%
30% 30%
20% 20%
Single campaign
10% 10%
0% 0%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Years
39. The role of commercial sector
Emerging data from Uganda and Nigeria seem to support this
Within 5 months of free distribution 4-9% of households
procured an additional net from the commercial market
10
% of household buying commercial net after free net
8.9 ANC
9
Campaign
8
7
6
5.2
5
4.0
4
3
2
1
0
Adjumani Kano
45. Equity of distribution
Favouring the-poor
Concentration Curve Concentration Curve
100
Uganda ANC and campaign Mozambique, ANC
100
Cumulative percentage of households with intervention
90 90
Cumulative percentage of wealth quintiles
80
among hh with person to net ratio <=2.0
80
70 70
60 60
50 50
40 40
30 30
20 20
equity line
distribution
10 10
0 0
0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100
Cumulative percentage of wealth quintiles in sample Cumulative percentage of households
46. Impact of LLIN
Monitoring area Kamwenge, Uganda
100
90
Proportion with malaria parasites
80 Increased access
to health services
70
1994
60 1997
ACT introduced
1998
50 2007
2008
40 LLIN campaign
30
20
10
0
0 1 2 3 4 5 6
Age in years
47. The New Paradigm
• What do we mean?
– Global recognition of malaria problem
– Sufficient financing available
– Lofty ambitions
– Move from focus on burden reduction to focus on
transmission reduction
• What must this translate into?
– Converted into successful malaria control
– Particularly higher transmission countries.
• The heartland.
48. Scaling up and beyond
• Aggressive promotion of single solutions
– GFATM funding forcing policy (examples?)
– LLIN delivery through measles campaigns
– Home-management of malaria (one disease system)
• Toward single models for delivery
• Blunt instrument
• Some value:
– Increase coverage quickly
– Focus on a single delivery models for quick results
49. Scaling up and beyond
• Longer term thinking
• Reflect the diversity:
– Epidemiology
– Socio-economic settings
– Health systems
• Grounded/centred where the problem is
• Locus: local rather than global
50. Heightened advocacy The Paradigm Shift:
Global beyond burden,
Increasing pressure
conformity
progress towards transmission
2010 coverage targets
Si
ng
Bl l e
un so
t ,s lu
tio
ho ns
r t- to
te de
rm
in liv
st er
ru y
m
en
t
Range of delivery models
Epidemiology
Socio-economic settings
Health systems Local diversity
