ITNs in Africa: Balancing Sustainability and Equity A New RBM Consensus Strategy

1. ITNs in Africa: Balancing Sustainability and EquityA New RBM Consensus Strategy Matthew Lynch Bureau for Global Health

2. The burden of malaria in Africa • Between 1-2.7 million deaths per year • 90% in Africa, mainly children • $3-12 Billion reduction in Africa’s GDP

3. Efficacy of ITNs • 22% reduction in infant deaths (1-12 mos) • 28% reduction in LBW to mothers using ITNs • 25% reduction in adverse birth outcomes • 47% reduction in maternal severe anemia • 30-70% reduction in child morbidity

4. Annual needs in LLITNs to protect the most vulnerable groups at risk of malaria in Africa(285 million people) Year 1 to year 5: • 115 million nets After year 7(maintenance) • 29 million nets/year

5. RBM Consensus Strategy: Three-part Approach • Commercial sector expansion to serve those households who can pay for ITNs • Subsidized time-limited interventions to prime the market • Targeted subsidies for the poor and areas of market failure

6. USAID: RBM partner • Commercial sector: Netmark Project • Transition from “classic” social marketing to market priming • Targeting our subsidies: • Antenatal services • voucher schemes • ?

7. National Scaling up for ITNs:A Strategic Framework for Partners Commercial Sector Public Sector National generic demand creation Consumer Information Brand-specific demand creation Consumer Protection & regulatory issues Create enabling environment Research Demand Creation Behavior Change Product Development Distribution to whole population at commercial price Transitional Opening of Markets Ensuring access of Vulnerable Groups Local demand creation Additional “niche” supply Distribution to special target populations NGOs

8. Market Priming Process Early Mid Late Development of commercial market Subsidizedtime-limited interventions Sustained equity provision

9. Early Phase • Little or no commercial interest in expanding the ITN market • Demand Creation • IEC for heightened awareness of benefits • Advocacy for Taxes & Tariffs exoneration • Market-priming

10. Market Priming • Demonstrate to traders ITNs are viable business • Establish trading networks for vigorous & competitive market • Differs for urban and rural areas

11. Evolution: Priming to Market Extension • time-limited, with clear evolution strategy and defined criteria for starting exiting process. • Limited-volume, # of nets distributed via subsidized activities explicitly agreed-upon in advance • measured in terms of total volume: non-subsidized sales and market-priming sales

12. Mid-phase • Active urban markets, prices dropping • increased knowledge/awareness, but... • rural market failure • highest-risk households underserved • little public health impact- but could be significant economic benefits

13. Late Phase • Highly developed commercial infrastructure • high awareness and utilization in households • continued need for targeted subsidies for vulnerable populations: pregnant women, young children, rural poor

14. The poor will always be with you... • Commercial market will not serve all households • highest need comes with lowest cash • Netmark/PSI collaboration, UNICEF & Netmark • targeting subsidies: vouchers, biology and geographic factors

15. Targeted Vouchers • Serves both: targeted to vulnerables, builds commercial market • Reduced logistic and management burden on health facilities • Tanzania starting first large-scale test with GFATM funds

16. Antenatal care in AfricaProportion of Pregnant Women Seeking Antenatal Clinic Care Demographic and Health Surveys

17. Summary • Focus on public health impact argues for: • Integrated strategy, donor coordination • public-private partnerships to ensure wide coverage • targeted subsidies to identified vulnerable groups • long-range strategy for phasing market priming assistance