Beyond Scaling Up
  Universal Access to Effective
Malaria Prevention and Treatment:
      how do we get there?

          ...
MALARIA - Introduction
          Malaria control rests on two major pillars

   Case                                      ...
Prevention with LLIN
    For many years the RBM Working Group on ITN (now Vector
    Control WG) has suggested a mixed mod...
Saving Lives,
Sustaining Gains
Nigeria: Support to the National Malaria Programme
                 CNTR 2007 07843

      ...
Our Vision
 Vulnerable groups are protected with LLINs and access
 effective treatment through public and private channels...
Public Health,
Private Markets
   Approach
Public Health Private Markets
     Aiming for sustained total coverage
                Each sector has unique strengths
Al...
Balance of components
 Creation of sustainable demand & supply across all populations


   Public and civil society
      ...
Attaining and Sustaining
        Coverage
The Evidence from Kenya
            Reviewed three different distribution models
1.   Traditional social marketing model b...
MCP Approach to Coverage
• Kenya data confirms a key element of the MCP
  approach – campaigns are necessary

• MCP recogn...
Malaria Consortium
   Sustaining LLIN/ITN Targets Model
• Developed by Malaria Consortium M&E and Research
  Department
• ...
Malaria Consortium Sustaining LLIN Targets Model
                                                  Dynamic Loss Function
 ...
Nigeria: total expected net output in 12
                project states
             4,500,000

             4,000,000

  ...
Nigeria – 12 project states
                                                  Campaigns children under 5
                 ...
Nigeria – 12 project states
                                              Campaigns children under 5 + ANC
               ...
Nigeria – 12 project states
                                          Campaigns children under 5 + ANC + commercial subsid...
Nigeria – 12 project states
                             Campaigns children under 5 + ANC + commercial subsidy + unsubsidi...
Sustaining LLIN/ITN
  Targets Model
Uganda: modelling scenarios of distribution
         Campaign distributions to all U5 & PW every 5 years, 50% polyethylene...
Uganda: modelling scenarios of distribution
                             Initial campaign U5 & PW then 80% of PW-ANC, 50% ...
Uganda: modelling scenarios of distribution
                                 Initial campaign U5 & PW then 80% of PW-ANC p...
Reaching the Poor
The Evidence from Kenya




Noor et al, 2007
The Evidence from Mozambique
                                                                  100
Cumulative % of househo...
Reaching the Poor - Prevention
• Kenya evidence
  – Shows free campaigns are pro-poor
  – Shows inequity of single-branded...
The reach of our partnership
                       Distribution Networks
                                      Sprin
    ...
Price Support for
 Sustainability
Price Support
• Price support is channelled through the commercial
  sector
• Implementing agency does not retain the pric...
Price support – does it work?

• Malaria Consortium experience in
  Mozambique and Uganda :
  – Increased commercial secto...
MCP commercial partners’ ITN sales,
          Mozambique
                       340,000
                       320,000
   ...
Examples of commercial sector development
                              100.0%                                            ...
Rapid Scale-up

Since 2005 increasing investments and since
2008 good progress in many countries
Based on modelling and pr...
Limitations of Campaigns
                                            However, loss of nets through “wear and tear” and oth...
Limitations of Campaigns
                                        Even repeated campaigns can not sustain high levels
     ...
Need for continuous distributions
Distributions are needed that supply LLIN to
target groups and/or customers in a
continu...
Channels for continuous distributions
  Primary distribution mechanisms are
    Routine health services (ANC/EPI)
    Comm...
Sustaining high coverage
                                        Modelling suggest that this mixed approach will sustain
 ...
The role of commercial sector
Emerging data from Uganda and Nigeria seem to support this

                                ...
Some Results
Distributing LLIN
              Number of LLIN distributed by MC                                         Contribution of c...
Retention of LLIN after 6 Months
                              100


                              90


                  ...
Equity of distribution
                                                                              Favouring the-poor
  ...
Impact of LLIN
                    Monitoring area Kamwenge, Uganda
                                    100

             ...
The New Paradigm
 • What do we mean?
   –   Global recognition of malaria problem
   –   Sufficient financing available
  ...
Scaling up and beyond
• Aggressive promotion of single solutions
  – GFATM funding forcing policy (examples?)
  – LLIN del...
Scaling up and beyond
• Longer term thinking
• Reflect the diversity:
  – Epidemiology
  – Socio-economic settings
  – Hea...
Heightened advocacy                          The Paradigm Shift:
   Global                                                ...
Beyond Scaling Up: Universal Access to Effective Malaria Prevention and Treatment. How do we get there?
Beyond Scaling Up: Universal Access to Effective Malaria Prevention and Treatment. How do we get there?
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Beyond Scaling Up: Universal Access to Effective Malaria Prevention and Treatment. How do we get there?

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This presentation was given at the 'Beyond Scaling Up: Pathways to Universal Access' workshop which was held at the Institute of Development Studies, Brighton on the 24-25 May, 2010. This event was co-sponsored by the Future Health Systems Research Programme Consortium and the STEPS Centre. Mehra presented on the work of the Malaria Consortium.

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Beyond Scaling Up: Universal Access to Effective Malaria Prevention and Treatment. How do we get there?

  1. 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. 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. 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
  4. 4. Saving Lives, Sustaining Gains Nigeria: Support to the National Malaria Programme CNTR 2007 07843 Malaria Consortium Partnership 2006
  5. 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.
  6. 6. Public Health, Private Markets Approach
  7. 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. 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
  9. 9. Attaining and Sustaining Coverage
  10. 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. 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. 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. 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. 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. 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. 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. 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. 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
  19. 19. Sustaining LLIN/ITN Targets Model
  20. 20. Uganda: modelling scenarios of distribution Campaign distributions to all U5 & PW every 5 years, 50% polyethylene, 50% polyester 10,000,000 100.0% 9,500,000 9,000,000 90.0% Proportion of hh with at least one net in % 8,500,000 8,000,000 80.0% 7,500,000 Number of nets distributed 7,000,000 70.0% DHS 6,500,000 2006 6,000,000 60.0% 15.9% 5,500,000 actual distribution 5,000,000 50.0% projected 4,500,000 ITN coverage 4,000,000 40.0% 3,500,000 DHS 2000/01 3,000,000 30.0% 2,500,000 1.6% 2,000,000 20.0% 1,500,000 1,000,000 10.0% 500,000 0 0.0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year
  21. 21. Uganda: modelling scenarios of distribution Initial campaign U5 & PW then 80% of PW-ANC, 50% polyethylene, 50% polyester 10,000,000 100.0% 9,500,000 9,000,000 90.0% Proportion of hh with at least one net in % 8,500,000 8,000,000 80.0% 7,500,000 Number of nets distributed 7,000,000 70.0% 6,500,000 6,000,000 60.0% 5,500,000 actual distribution 5,000,000 50.0% projected 4,500,000 ITN coverage 4,000,000 40.0% 3,500,000 3,000,000 30.0% 2,500,000 2,000,000 20.0% 1,500,000 1,000,000 10.0% 500,000 0 0.0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year
  22. 22. Uganda: modelling scenarios of distribution Initial campaign U5 & PW then 80% of PW-ANC plus 25% of households buy, 50% polyethylene, 50% polyester 10,000,000 100.0% 9,500,000 9,000,000 90.0% Proportion of hh with at least one net in % 8,500,000 8,000,000 80.0% 7,500,000 Number of nets distributed 7,000,000 70.0% 6,500,000 6,000,000 60.0% 5,500,000 actual distribution 5,000,000 50.0% projected 4,500,000 ITN coverage 4,000,000 40.0% 3,500,000 3,000,000 30.0% 2,500,000 2,000,000 20.0% 1,500,000 1,000,000 10.0% 500,000 0 0.0% 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Year
  23. 23. Reaching the Poor
  24. 24. The Evidence from Kenya Noor et al, 2007
  25. 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. 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. 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
  28. 28. Price Support for Sustainability
  29. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
  40. 40. Some Results
  41. 41. Distributing LLIN Number of LLIN distributed by MC Contribution of countries 10,000,000 8,904,048 9,000,000 8,000,000 7,000,000 Nigeria, 1,885,000, 21% 6,000,000 5,654,329 Uganda, 3,773,897, 43% 5,000,000 Southern Sudan, 399,320, 4% Sudan, 188,100, 2% 4,000,000 3,382,287 3,000,000 Mozambique, 2,657,731, 30% 2,000,000 1,000,000 657,612 10,000 47,135 144,512 0 2003 2004 2005 2006 2007 2008 2009
  42. 42. Retention of LLIN after 6 Months 100 90 80 Proportion of nets retained 70 60 50 40 30 20 10 0 Adjumani Jinja Katakwi Kitgum Gulu Cabo Inhambane Nampula Manica Sofala Delgado Uganda Mozambique
  43. 43. 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
  44. 44. 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
  45. 45. 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.
  46. 46. 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
  47. 47. 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
  48. 48. 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

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