Beyond Scaling Up: Universal Access to Effective Malaria Prevention and Treatment. How do we get...
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Transcript of Beyond Scaling Up: Universal Access to Effective Malaria Prevention and Treatment. How do we get...
Universal Access to Effective Malaria Prevention and Treatment:
how do we get there?
Sunil MehraExecutive Director, Malaria Consortium
with contributions from Dr. Albert Kilian, Dr. Sylvia Meek, Dr. Graham Root,
and Caroline Vanderick
Beyond Scaling Up
MALARIA - IntroductionMalaria control rests on two major pillars
Within the prevention arm Long-Lasting Insecticidal Nets (LLIN) form the most important intervention in sub-Saharan Africa
Parasite Vector
Host
EnvironmentEnvironmentIRS
LLIN
EnvironmetalManagement
Treatment
IPTp
IPTi
PreventionCase Management
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
Long term targeted subsidies for most vulnerable
Short term subsidies to encourage ITN market growth
Unsubsidized commercial expansion for sustainability
Donor funding
Domestic funding
Time
2003
2010
Saving Lives, Sustaining Gains
Nigeria: Support to the National Malaria ProgrammeCNTR 2007 07843
Malaria Consortium Partnership2006
Our Vision
Vulnerable groups are protected with LLINs and accesseffective treatment through public and private channels.
Informed households, including poor, demand for and canobtain 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.
Public Health, Private Markets
Approach
Public health private markets extends the potential of each sector through an inclusive and pluralistic approach
Public Health Private Markets Aiming for sustained total coverage
Public Sector
Improving delivery of health services,
setting policies, stewardship
Civil Society
Focus on the poor and marginalised
Commercial Sector
Improving access through competition
Each sector has unique strengths
All contribute to public health, none alone can achieve total coverage
Balance of components
Key strategy: demand creation and a blended distribution system for sustained and equitable
impact
Ensures equity and targeting
Achieves rapid results
Helps open up mass market demand
Public and civil society
sector component
4.4 million free LLINs through
campaigns
SMoH supported to distribute
5 million LLINs through ANC
Quality of care improved in
6,500 health facilities
30 million doses of SP for IPT
provided
Mass market response and lower pricing leads to long-term sustainability
Commercial sector support
10 million subsidised LLINs
through commercial sector
9.5 million subsidised <5yrs
ACTs at 10 cents each
Creation of sustainable demand & supply across all populations
Attaining and Sustaining Coverage
The Evidence from Kenya
Reviewed three different distribution models1. Traditional social marketing model by PSI2. Health facility based distribution of subsidised nets ($0.70)3. Campaign distribution of free ITNs to under-fives
Two key findings1. Only campaigns able to reach high coverage levels quickly2. 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
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
• 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
Malaria Consortium
Sustaining LLIN/ITN Targets Model
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 2 4 6 8 10 12 14 16 18
Time in years
Pro
po
rtio
n o
f n
ets
sti
ll in
use Polyethylene
Polyester
Malaria Consortium Sustaining LLIN Targets Model
Dynamic Loss Function
Nigeria: total expected net output in 12 project states
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
4,500,000
1 2 3 4 5
Year
Ne
t o
utp
ut
campaign
routine
LLIN subsidy
unsubsidized
Nigeria – 12 project states
Campaigns children under 5
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
10,000,000
0 1 2 3 4 5
Year
Nu
mb
er
of
ne
ts d
istr
ibu
ted
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Pro
po
rtio
n o
f h
h w
ith
at
lea
st
on
e n
et
in %
total net output
commercial
ITN coverage
Nigeria – 12 project states
Campaigns children under 5 + ANC
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
10,000,000
0 1 2 3 4 5
Year
Nu
mb
er
of
nets
dis
trib
ute
d
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Pro
po
rtio
n o
f h
h w
ith
at
leas
t o
ne
ne
t in
%
total net output
commercial
ITN coverage
Nigeria – 12 project states
Campaigns children under 5 + ANC + commercial subsidy
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
10,000,000
0 1 2 3 4 5
Year
Nu
mb
er
of
ne
ts d
istr
ibu
ted
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Pro
po
rtio
n o
f h
h w
ith
at
lea
st
on
e n
et
in %
total net output
commercial
ITN coverage
Nigeria – 12 project states
Campaigns children under 5 + ANC + commercial subsidy + unsubsidized
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
10,000,000
0 1 2 3 4 5
Year
Nu
mb
er
of
nets
dis
trib
ute
d
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Pro
po
rtio
n o
f h
h w
ith
at
leas
t o
ne
ne
t in
%
total net output
commercial
ITN coverage
Sustaining LLIN/ITN Targets Model
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
4,500,000
5,000,000
5,500,000
6,000,000
6,500,000
7,000,000
7,500,000
8,000,000
8,500,000
9,000,000
9,500,000
10,000,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Year
Nu
mb
er
of
ne
ts d
istr
ibu
ted
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Pro
po
rtio
n o
f h
h w
ith
at
lea
st
on
e n
et
in %
actual distribution
projected
ITN coverage
Uganda: modelling scenarios of distribution
DHS 2000/01
1.6%
DHS 2006
15.9%
Campaign distributions to all U5 & PW every 5 years, 50% polyethylene, 50% polyester
Uganda: modelling scenarios of distributionInitial campaign U5 & PW then 80% of PW-ANC, 50% polyethylene, 50% polyester
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
4,500,000
5,000,000
5,500,000
6,000,000
6,500,000
7,000,000
7,500,000
8,000,000
8,500,000
9,000,000
9,500,000
10,000,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Year
Nu
mb
er
of
ne
ts d
istr
ibu
ted
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Pro
po
rtio
n o
f h
h w
ith
at
lea
st
on
e n
et
in %
actual distribution
projected
ITN coverage
Uganda: modelling scenarios of distributionInitial campaign U5 & PW then 80% of PW-ANC plus 25% of households buy,
50% polyethylene, 50% polyester
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
4,500,000
5,000,000
5,500,000
6,000,000
6,500,000
7,000,000
7,500,000
8,000,000
8,500,000
9,000,000
9,500,000
10,000,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Year
Nu
mb
er
of
ne
ts d
istr
ibu
ted
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Pro
po
rtio
n o
f h
h w
ith
at
lea
st
on
e n
et
in %
actual distribution
projected
ITN coverage
Reaching the Poor
The Evidence from Kenya
Noor et al, 2007
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80 90 100
Cumulative % of all households by wealth quitile
Cu
mu
lati
ve
% o
f h
ou
se
ho
lds
wit
h i
nte
rve
nti
on
by
wea
lth
qu
inti
le Equity line
Com LLIN
Pub LLIN
SM LLIN
Concentration Curve
Concentration Index
Public -0.11
Commercial +0.11
Social Marketing +0.42
Equity of LLIN by Distribution Mechanism
The Evidence from Mozambique
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
The reach of our partnershipDistribution Networks
CHAN MediPharm –Depots serving all six
zones
Rosies Textiles –
distribution network
for SE, SW and Kano
C.Zard – over 150 retailers country-wide
Springfields/Afcott –extensive cotton farmers network
Patemglobal –
nationwide
distribution network
Harvestfield –extensive distribution network in south
Pharmaceutical
manufacturers – well
structured networks
Price Support for Sustainability
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
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
MCP commercial partners’ ITN sales, Mozambique
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
160,000
180,000
200,000
220,000
240,000
260,000
280,000
300,000
320,000
340,000
NO
V
DE
C
JA
N
FE
B
MA
R
AP
R
MA
Y
JU
N
JU
L
AU
G
SE
P
OC
T
NO
V
DE
C
JA
N
FE
B
MA
R
AP
R
MA
Y
JU
N
JU
L
AU
G
SE
P
OC
T
NO
V
DE
C
2005 2006 2007
Cu
mu
lati
ve I
TN
sa
les
institutional
retail
Examples of commercial sector development
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Pro
po
rtio
n o
f n
ets
LL
IN
0
500,000
1,000,000
1,500,000
2,000,000
2,500,000
3,000,000
3,500,000
4,000,000
4,500,000
5,000,000
To
tal
nu
mb
er
of
nets
public and civil society
social marketing
commercial partners
estimated informal market
% LLIN
Uga
nda
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
Limitations of CampaignsHowever, loss of nets through “wear and tear” and other behavioural
factors starts early
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Years
Ho
useh
old
s w
ith
at
lea
st
1 IT
N
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5 6 7 8
Years
Togo
Sofala - Moz
Manica - Moz
Law ra - Ghana
Model Field data
Limitations of CampaignsEven repeated campaigns can not sustain high levels of coverage in an continuous fashion
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Years
Ho
us
eh
old
s w
ith
at
lea
st
1 IT
N
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
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)
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
Sustaining high coverageModelling suggest that this mixed approach will sustain
high coverage (emerging support from data)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Years
Ho
us
eh
old
s w
ith
at
lea
st
1 IT
N
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
ANC 85% & 40% hhANC 85% & 20% hh
Single campaign
The role of commercial sectorEmerging data from Uganda and Nigeria seem to support this
8.9
5.2
4.0
0
1
2
3
4
5
6
7
8
9
10
Adjumani Kano
% o
f h
ou
se
ho
ld b
uyin
g c
om
me
rcia
l n
et
aft
er
free
ne
t
ANC
Campaign
Within 5 months of free distribution 4-9% of householdsprocured an additional net from the commercial market
Some Results
Distributing LLIN
10,000 47,135 144,512
657,612
3,382,287
5,654,329
8,904,048
0
1,000,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
10,000,000
2003 2004 2005 2006 2007 2008 2009
Sudan, 188,100, 2%
Southern Sudan, 399,320, 4%
Mozambique, 2,657,731, 30%
Uganda, 3,773,897, 43%
Nigeria, 1,885,000, 21%
Number of LLIN distributed by MC Contribution of countries
Retention of LLIN after 6 Months
0
10
20
30
40
50
60
70
80
90
100
Adjumani Jinja Katakwi Kitgum Gulu Cabo
Delgado
Inhambane Nampula Manica Sofala
Pro
po
rtio
n o
f n
ets
reta
ine
d
Uganda Mozambique
Equity of distribution
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
Cu
mu
lati
ve p
erc
en
tag
e o
f w
ealt
h q
uin
tile
s
am
on
g h
h w
ith
pers
on
to
net
rati
o <
=2.0
equity line
distribution
Concentration Curve Uganda ANC and campaign
Concentration Curve Mozambique, ANC
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 households
Cu
mu
lati
ve p
erc
en
tag
e o
f h
ou
seh
old
s w
ith
in
terv
en
tio
n
Favouring the-poor
Impact of LLIN
0
10
20
30
40
50
60
70
80
90
100
0 1 2 3 4 5 6
Age in years
Pro
po
rtio
n w
ith
ma
lari
a p
ara
sit
es
1994
1997
1998
2007
2008
Monitoring area Kamwenge, Uganda
Increased accessto health services
ACT introduced
LLIN campaign
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.
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
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
Global conformity
� Heightened advocacy
� Increasing pressure
� 2010 coverage targets
Local diversity
Single solutions to delivery
Blunt, short-term instrum
ent
Range of delivery models
� Epidemiology
� Socio-economic settings
� Health systems
Global progress
The Paradigm Shift: beyond burden, towards transmission