REACHING THE POOR WITH INSECTICIDE-TREATED NETS: THE TANZANIAN EXPERIENCE WITH VOUCHERS AND FREE NETS Rose Nathan Ifakara Health Institute Kara Hanson Ifakara Health Institute and London School of Hygiene and Tropical Medicine
OUTLINE 1. Background ITNs in Tanzania 2. Early experience with vouchers the KINET project 3. Scaling up vouchers to national level: The Tanzania National Voucher Scheme 4. Free nets for <5s Will it address the equity issue? 5. The future for ITN delivery in Tanzania
THE DELIVERY CHALLENGE ITNs shown to be effective and cost effective at reducing all-cause child mortality But coverage still short of international targets There are a number of possible ways to deliver nets which are likely to differ in terms of level of coverage, tempo, equity, sustainability, health system impact, etc. Better evidence needed to guide policy
HH ITN ownership ITN use by <5s ITN use by pregnant women Source: World Malaria Report 2008
A BRIEF HISTORY OF NETS IN TANZANIA Nets as business: First factory begins producing finished nets in 1994, by 2007 4 manufacturers with local sales >2.5 million Research on ITNs: Tanzania home for studies showing effects of ITNs on health and survival, experimentation with delivery systems 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 Sales of Bednets in Tanzania 2001-2007 2001 2002 2003 2004 2005 2006 2007 Unsubsidised nets Olyset TNVS Free nets
KILOMBERO VALLEY INSECTICIDE- TREATED NET (KINET) PROJECT, 1997-2000 First evaluation of health impact of ITNs in an operational (vs.trial) setting Social marketing of pre-treated nets + insecticide retreatment kits combined with voucher targeted at pregnant women Demonstrated a 27% reduction in child mortality Voucher scheme was feasible Coverage increased as much in poorest as in least poor quintile
HOUSEHOLD NET OWNERSHIP BY SES IN 1997 AND 2000 KILOMBERO AND ULANGA DSS AREAS Household owing nets (%) 100 90 80 70 60 50 40 30 20 10 0 Q1 (Poorest) 2 3 4 Q5 (Least poor) Asset score (quintile) Equity ratio (Q1/Q5) 1997: 0.31 2000: 0.59 1997 2000
NATIONAL ITN STRATEGIC PLAN (2000) Encourage development of commercial ITN market: SMITN and SMARTNET projects Advocacy for tax and tariff reform Initiated 100% bundling with insecticide Technology transfer (LLINs, long-lasting treatment) Information campaigns and promotion materials Extension of distribution networks Targeted subsidy to vulnerable groups Tanzania National Voucher Scheme (TNVS) for ITNs, Hati Punguzo: partial subsidy, mixed delivery system integrated with health system Global Fund Round 1 award; 2007 Rolling Continuation Channel award; US PMI support to voucher scheme
WHY VOUCHERS? Consumer-led demand-side financing: subsidy + choice Targeted at particular group Provides a link between public and private sectors Desire to support commercial net distribution system, in face of targeting and sustainability concerns Concerns about burden to public sector of logistics and management of net stock
HATI PUNGUZO Only health voucher scheme to operate in LIC at national scale? Fixed value discount voucher (TSh32500 = US$2.75) redeemable against purchase of ITN (2010 changed to fixed top-up) Provided to all pregnant women at antenatal clinic (infant voucher introduced 200?7)
THE TNVS VOUCHER FLOW Redeemed vouchers Redeemed Vouchers Manufacturers MEDA Voucher Books Wholesalers District Medical Officers & RCH Clinics Redeemed Vouchers Retailers Pregnant Women Individual Vouchers Source: NATNETS Individual Vouchers
USE OF NETS IMPROVED DRAMATICALLY 2005-7 ITN USE DOUBLED 2005-7 BUT LITTLE PROGRESS 07/08 2005 2006 2007 2008 Any ITN Any ITN Any ITN Any ITN Pregnant women 25 11 34 18 39 23 38.6 18.8 Infants 33 16 48 28 56 34 47.2 31.2 <5s 28 15 41 21 47 26 48.3 28.8 Source: TNVS Household surveys 2005-8
...AND NET TREATMENT REMAINED A CHALLENGE 2005 2006 2007 2008 Any ITN Any ITN Any ITN Any ITN Pregnant women 25 11 34 18 39 23 38.6 18.8 Infants 33 16 48 28 56 34 47.2 31.2 <5s 28 15 41 21 47 26 48.3 28.8 Source: TNVS Household surveys 2005-7
PERCENT OF NETS REPORTED TO BE PURCHASED WITH A VOUCHER 2005 2006 2007 Designcorrected p- value for difference across years Households with child < 1 7 % 38% 50% <0.001 Households with child < 5 4% 19% 34% <0.001 Households with currently pregnant woman Households with neither children < 5 nor pregnant women 6% 19% 24% <0.001 1% 4% 4% <0.001
CONTEXT: COVERAGE OF OTHER HEALTH SYSTEM INTERVENTIONS (2007) Voucher coverage = 57% (70% in 2006) IPTp(1) = 65% IPTp(2) = 30% Availability of SP = 59% Antenatal cards in stock = 90% Child vaccination cards in stock = 82% Vouchers in stock = 80%
BUT STEEP SOCIOECONOMIC DIFFERENCES: ANY NET COVERAGE IN INFANTS BY SES, 2005-7 90 80 70 60 50 40 30 20 10 0 Q1 Q2 Q3 Q4 Q5 Equity ratio: 2005: 0.14 2006: 0.36 2007 : 0.41 2008: 0.47 2005 2006 2007 2008
UNDERSTANDING SOURCES OF INEQUITY To use a net women must: 1. Attend ANC 2. Receive a voucher 3. Redeem their voucher at a shop This process will be supported through: Knowledge and understanding of the voucher process Inequalities in final outcome (net use in any target group) can arise because of failures at any level
ANC use by SES (2007) Equity ratio = 0.95 100 90 80 70 60 50 40 30 20 10 0 Q1 Q2 Q3 Q4 Q5 Voucher redemption by SES (2007) Equity ratio = 0.82 Voucher receipt by SES (2007) Equity ratio = 0.86 100 90 80 70 60 50 40 30 20 10 0 Q1 Q2 Q3 Q4 Q5 Hati Punguzo knowledge by SES (2007) Equity ratio = 0.86 100 90 80 70 60 50 40 30 20 10 0 Q1 Q2 Q3 Q4 Q5 100 90 80 70 60 50 40 30 20 10 0 Q1 Q2 Q3 Q4 Q5
CUMULATIVE EFFECT OF INEQUITIES (2007) Delivery effectiveness =.94*.67*.64 = 0.40 Delivery effectiveness =.94*.78*.78 = 0.60 Poorest quintile Least poor quintile
GEOGRAPHIC INEQUITIES: DISTRIBUTION OF M&E DISTRICTS BY LAUNCH PHASE RED (EARLY) GREEN (MIDDLE) PURPLE (LATE)
GEOGRAPHIC INEQUITIES: SES BY LAUNCH PHASE 35 30 25 20 15 10 5 Q1 Q2 Q3 Q4 Q5 0 Early Middle Late Oct 04 May 05 June 05 Oct 05 Nov 05 May 06
ACTION TO IMPROVE COVERAGE AND EQUITY: TARGETED AND UNIVERSAL APPROACHES 2006: US Presidents Malaria Initiative provides funds an equity voucher to finance top-up for the poorest women - a failure 2007: Plans developed for catch-up massdistribution of LLINs; Implementation through a rolling plan, beginning May 2009; Universal coverage campaign to start 2010. Geographic targeting: start with those districts with the highest malaria burden Maintain keep-up system through voucher scheme, change to fixed top-up (TSh 500 = USD0.40) and LLINs (Olyset)
ASSESSMENT OF IMPACT OF <5 CATCH-UP CAMPAIGN Household survey to assess: ITN coverage among children under five years in the Southern and Lake zones Free net coverage for children under five years in the Southern and Lake zones Household coverage of the hang-up campaign in the Southern and Lake zones Retreatment campaign in Southern zone Retail survey to assess: Retail supply response to free mass distribution
2009 HOUSEHOLD SURVEY - METHODS Where? Southern zone (Nachingwea and Mtwara urban) Lake zone (Rorya, Chato and Sengerema) Sample 10 clusters (wards) per district and 30 households per cluster How? Household survey using a structured questionnaire PDAs used to capture data When? October-December 2009
2009 RETAIL SURVEY Objective: To assess retailer response to the <5 and universal campaigns Methods: Sampling: How to capture those who may have stopped selling nets Indicators: Stocking patterns (mix of ITNs and LLINs, retreatment) Sales volumes (voucher and non-voucher; LLIN and conventional) Prices Qualitative responses : Concerns, credibility of commitment to dual strategy
WILL THE <5 CATCH UP CAMPAIGN LEAD TO IMPROVED COVERAGE AND EQUITY? New system removes financial and process barriers But will it be sufficient to ensure high and sustained use? Monitor: Processes: Level and socioeconomic distribution of registration of <5, receipt of LLIN, hang-up campaign Contributions of different delivery systems to coverage in different SE groups (see next slide) Effect on the gap between ownership and use Behavioural / Cultural / Seasonal differences? Effect on the gap between any-net and ITN use
CONTRIBUTIONS OF DIFFERENT DELIVERY SYSTEMS TO < 5 NET USE, KENYA, 2006/7 Source: Noor et al. PLOS Medicine 2007
WHAT NEXT FOR ITNS IN TANZANIA? Universal coverage campaign to start 2010 Need to monitor carefully the effect of the catch-up campaigns on ITN use, equity and potentially, retail sector availability and prices Ongoing discussions on future form of keepup strategy
ACKNOWLEDGEMENTS Global Fund, through grant to Ministry of Health and Social Welfare Gates Malaria Partnership DFID and Royal Netherlands Embassy, through Population Services International US President s Malaria Initiative National Malaria Control Programme (Dr Alex Mwita, Dr Renata Mandike, Nick Brown) NATNETS Implementing Partners