Developing a Sustainable ITN Market for Malaria Prevention, Mozambique

Delivery systems for nets rely on either public health campaigns or the commercial sector. There are limitations to both, and there is no single answer for the best, most cost effective delivery system. Public health programmes get high coverage of nets, but they must be backed up by awareness campaigns and household education in the use of nets, whereas private commercial delivery systems suffer from inequitable access with significant association between household wealth, mother's education, distance from commercial centre and the coverage and use of nets. Social marketing - the use of commercial marketing techniques to change people's behaviour (i.e. in terms of using a net regularly) - appears to be both useful and important, but few studies have compared its cost effectiveness with other techniques.

The British Department for International Development (DFID) has funded a five year programme grant of 15 million USD which began in June 2005. Funding is awarded in two equal phases. The first phase runs from June 2005 to December 2007, with the second phase from January 2008 to May 2010. The two principal components of the programme involve distribution of long lasting insecticidal nets (LLIN) through health facilities to pregnant women and the development of a commercial market for insecticide treated nets (ITN) by working with existing private sector systems and companies. To undertake this programme, the Malaria Consortium Partnership (MCP) was formed with a variety of private (eg. Agrifocus, Proserv Lda) and public sector (e.g. RBM Facilitators Group) organisations, both national and international.

Public Sector

During the first phase, most activities in the public sector are focusing on the three provinces of Inhambane, Nampula and Cabo Delgado, with models for LLIN distribution through the health sector developed to allow national scaling up. These provinces were assigned by the National Malaria Control Programme based primarily on levels of existing malaria control activity and the burden of malaria. Thanks to the close collaboration and expertise of the provincial health authorities, we have been able to define operational policies and strategies that have led to effective implementation and positive results.

• There has been rapid roll out of the system: In 2006, nearly 80,000 LLIN were distributed across Inhambane province through the 182 Ante Natal Clinics and outreach services. In Nampula and Cabo Delgado provinces a further 110,000 LLIN were distributed.
• A total of at least 400, 000 LLIN will be distributed in Phase 1 in the three provinces.
• In one month, 208 maternal and child nurses in Inhambane province were trained to use the distribution system developed for the programme. This system and the training were developed in consultation with the provincial health office. In Nampula and Cabo Delgado provinces 277 and 136 health workers respectively were trained. Given the evident success of the system, return of monthly monitoring materials, and requests for additional training in other areas of malaria control, the training is considered to have been successful.
• A campaign to reach children under five will be run in Cabo Delgado together with the provincial health authorities in September/October 2007.
• Almost 50,000 nets originally ordered by UNICEF using DFID funding were distributed in Inhambane. These nets were ordered untreated and, as MC has a commitment to providing effective protection, we organised the purchase and partial donation from our partner Bayer, of KO tab 123 long lasting insecticide in order to treat these nets prior to their distribution. This move was agreed by the NMCP.

Commercial Strategy

Given the many brands of ITN that already exist and that commercial distribution systems for other products are already present in Mozambique, the MCP has chosen to support existing brands, commercial businesses and networks to increase the market availability of ITN and LLIN in Mozambique. This is being done through technical assistance, promotional collaboration and a package of subsidies and financial assistance designed to provide incentives and ensure a quality product. We recognize the risks and start-up costs for entering and/or developing a new market or product and, with the input of commercial sector partners at all levels, have developed an effective strategy to reduce this exposure and encourage the commercial sector to invest. Our approach bolsters existing commercial networks by providing additional products which importers, wholesalers and retailers can sell successfully. This approach taps existing strengths in distribution, channels market forces such as competitionfor public good, and requires minimal staffing, thus focusing resources where they will have the most impact. With thoughtful, strategic investment and support, this approach will lead to a sustainable market for ITN.

• ITN and LLIN are sold at prices roughly competitive with the untreated nets currently on the market; whilst slightly more expensive, the added benefits of quality, longer life and increased protection far outweigh the marginal added cost. One of the aims of the communications strategy described below is to educate people about the increased protection provided by ITN, thus increasing its perceived value and encouraging the small additional investment necessary to own one.

Investing now in "priming" the market, creating policies favourable for commercial sector ITN/LLIN distribution, and cultivating commercial sector partners will pay off in the long term by reducing the burden on the public health system.

Communications Strategy

The programme communications strategy supports two programme elements - the Public Sector and Private Sector - and includes activities specific to each as well as generic promotion. The main objectives are for families to make sure:

• pregnant women sleep under an ITN every night,
• children under five sleep under an ITN every night
• ITNs are hung and cared for correctly.

Recognizing that very little mass media reaches the rural areas, and the low literacy rate, social mobilization is the core of our approach, working through local leaders and networks. This is complemented by a mass media strategy in the urban areas.

In addition, our communications team has developed, tested, and refined materials for educating health workers and community members about malaria control.

M&E Component

Accurate and reliable information is a critical tool in making policy decisions. MCP is committed to obtaining reliable information and conducting careful analysis. In addition to monitoring malaria morbidity and mortality in pregnant women and children under five in collaboration with NMCP, the monitoring and evaluation activities planned for the project include:

1. Household survey - initial plans to implement a programmatic baseline survey in the three provinces to determine knowledge of malaria and nets, availability of nets, reasons for net use and more have been incorporated into a far broader national level Malaria Indicator Survey (MIS). With the support of the US President's Malaria Initiative, the MIS will begin implementation in May 2007.
2. Market analysis- a baseline retail outlet survey was undertaken in August 2006 to determine availability of ITN on the current market in the three provinces. Two follow-up surveys will be conducted to monitor changes during the rainy season and one year after the first survey.
3. Net tracking study (Net Use Survey) - assesses retention and utilisation of nets distributed to pregnant women and has been incorporated into routine supervision activities.
4. Cost analysis of delivering insecticide-treated nets through the private or public sector -identifying the costs of net distribution through the different systems with the aim of assessing the equity and sustainability of the combination of distribution models.
5. Behavioural analysis - to examine changes in behaviour with regard to nets, the impact of communications messages and accessibility and acceptability of delivery systems.

For more information from DFID please click here

Photos and graph: Malaria Consortium