Sustainable Malaria Prevention

1. Sustainable Malaria Prevention DSA Conference 16th November 2013 Roger Oakeley (with thanks to Christian Lengeler; Swiss Tropical and Public Health Institute)

2. The Problem... “Where malaria prospers most, human societies have prospered least” • Mortality • Poverty • Social cost The Statistics: • 1m Deaths per year • 85% Children under 5 • Reduced economic growth by 1.3% per year – more than one third of average growth rates • 40% of healthcare spending in endemic countries • Cost on average $93/year not including lost productivity where many live on >$1/day Source: DFID (2010) Sachs & Malaney (2002)

3. Solutions: Big Numbers, Small Impacts.. • $1.71bn committed by donors to tackle malaria in 2010 • Different technical solutions • Bed nets • Untreated • Insecticide treated • Long-term insecticide treated • Spraying within households • Stagnant water clearance • Preventative medicine • 2.2% average annual reduction in incidence of malaria/1000 population 2001-2009 • Still there are 214 cases per 1000 population annually in Africa

4. Insecticide-treated bed nets (ITNs) A mosquito net... ... Treated with insecticide • Reduce child mortality (1-59 months) in Africa by 20% • Equivalent to 5.5 deaths/year per 1,000 protected children • With 80m children under 5 at risk in Africa, 480,000 deaths per annum could be saved if access to nets were improved • Source: Lengeler (2008)

5. How Attainable is Sustainable? A tale of two approaches • Universal Distribution • Buying nets & distributing them to people • Immediate Impact • Need replacing every 3-5 years • Coverage estimated to cost $6.2bn annually. • Market Development • Slow growth in impact • Aligns with incentives of consumers and suppliers • Requires limited ongoing donor support • If health systems aren’t working, we need to find new solutions, not recreate existing ones. • Can’t ignore the realities – where states aren’t providing, people are addressing their needs through non-state and hybrid solutions • Guinea: 93% of health expenditure takes place outside state sector • Source: Leach et al

6. Case Study: Tanzania • Low donor levels of interest in malaria prevention 1970-2000 • Tanzania one of worst affected countries with low coverage • 35m people; 6.4m under 5; 1.4m pregnant • 100,000 deaths/year; 80,000 under 5s • 1999: regular treated net use only 10% (nets approx $6-10 each) • In 2000 NATNETS programme launched as a coordinated strategy to increase coverage to 60% of ‘at risk’ by 2007.

7. An integrated approach.... SMARTNET Coordination Unit TNVS Social Marketing “..having bednets in stock wherever and whenever they are needed does not cost much but somebody must be motivated to do it. Motivation is the most precious asset in making the delivery system work.” NATNETS partner

8. ...for a better functioning, pluralistic system Ministry of Health Enabling environment Medical Stores Department Private sector devt. Wholesaler Manufacturer Districts, then clinics NETS Retailer VOUCHERS Pregnant woman attending ANC or child coming for measles immunisation Bed net consumers

9. Results: net sales and ownership 13m+ ITNs (2002-07) 3m+ ITNs/year 12.5m kits (2002-07) 4.9m vouchers (2002-07)

10. -24% -31% Results: Impact on child mortality 24% improvement in under 5 mortality rates (39,200 deaths less each year) Source: Tanzania DHS surveys Macro Int’l

11. Results: commercial sector development 250 wholesalers 6,900 retailers 4 manufacturers Source: SOAS (2011)

12. Creating Sustainable Incentives High risk groups • Those who need, get! • Contribution = recognition of value Consumers • Accessibility & choice • Social value – health & well-being Manufacturers • Increased demand • Business development Retailers • Commercial returns on transport, logistics, stock & marketing Government • Improved health + jobs + economic growth (+ votes!)

13. The future – not without challenges.. • Problems Exist • How to ensure at risk groups are covered quickly • Exogenous price factors e.g. Oil • Government contribution uncertain • Donor distortion • Ideological aversion • Viability void – heavy subsidy necessary • But what is the real alternative... • 2007 donor review of malaria prevention in Dar es Salaam • Major change in strategy post 2007 – an experiment with sustainability?

14. Sachs on Sustainability (?) “...you are worried about sustainability? Get over it. You have everything upside down. The only true lack of sustainability is the millions of lives being lost in Africa as you dribble out bed nets in this ridiculous social marketing campaign”

15. The changing policy landscape • Post 2007 meetings donor & government strategy was reversed: • The Policy... • WHO Advocated free distribution • UN Called for Universal coverage • Government of Tanzania received a $200m grant from the Global Fund & the President’s Malaria Initiative for free distribution of over18m nets • The Practice... • Universal coverage campaign ‘ended’ in 2011 • Donor funds diverted to other high need countries (Nigeria, DRC) • Demand in private market has collapsed • Factories reduced production except where local procurement arrangements (at higher prices than Asian imports) have been made • DFID commissioned new programme in 2012 to support local manufacturing and distribution capacity

16. Interpretations of 2007-2012 Policy Change • Manufacturing capacity reduced due to increase in cheaper imports • Jobs lost • Demand reduced through free distribution • Future demand reduced through the expectation of free distribution • Qualitative value placed on net reduced through non-contribution • Higher long-term incidence of malaria

17. Conclusions • Impacts can only be accurately assessed when considered in light of the long-term consequences of intervention • Sustainability is at the heart of everything we do in development • How we approach development problems – means rather than the end one hopes to achieve – is the greatest determinant of sustainability • A lack of appreciation of sustainability can (and often does) mean that interventions have a negative long-term impact despite their immediate results