Targeting malaria risk groups with subsidised ITNs in Malawi

1
Targeting malaria risk groups with subsidised
ITNs in Malawi

• Charles Yuma
• Desmond Chavasse
• PSI/Malawi

2
Demand for ITNs vs. malaria risk

• Everybody wants to own an net
• 90 state lack of money as reason for
  non-ownership
• Demand for nets is price sensitive
• Effective promotion can increase demand at a
  specific price but by how much?
• Risk of malaria disease and death is highest
  amongst rural poor
• Demand is lowest amongst those most at risk

3
Net and radio ownership by socio-economic status
4
Challenges to reaching high risk rural areas
Urban Rural Cash
available Yes No Efficient distribution
channels Yes No Good knowledge / progressive
attitudes Yes No Efficient communications
channels Yes No Malaria health
problem Small Big of national population
Small Big
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Principal challenges to large scale ITN programmes

• General
• Efficiently reach a population with nets where
  the spectrum of malaria risk is inversely
  proportional to socio-economic status. i.e
  maximise impact per dollar of public funding
• Specific
• Maximise revenue from those who can pay
• Target subsidy for those who cannot

6
ITN delivery models in Malawi

• Commercial sector distribution
• Health facility distribution
• Community based distribution

7
Commercial distribution

• Tax/tariffs have not been lifted (35)
• Low private sector activity
• PSI/Malawi supplies a blue conical net
• - preferred by urban residents
• - sales 100,000 per year
• - retails US 5
• - revenue US 4 (20 above product cost)
• Advantages Efficient/ self sustaining
• Disadvantages Low health impact

8
Health facility model (1)Why use health
facilities?

• Reach malaria risk groups directly (PWUF)
• Over 90 of pregnant women attend at least once
• Professional consultation opportunity
• Rural distribution of health facilities
• Established registration system
• Accountability is straightforward
• 97 of pregnant women perceive malaria risk to
  themselves or child
• TZ experience shows 98 of nets remained in
  purchasing household

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Health facility model (2)Product, price, sales

• Green square net (6x6)
• Pregnant women and children under 5 eligible
  only. Warning on net for trade
• Consumer price US 0.62 (from 5.11.02)
• Revenue US 0.5 (70 subsidy)
• Estimated sales 1-1.5 million p.a.
• At this rate of distribution Abuja target will be
  reached by 2005 deadline

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Health facility model (3)Procedures for roll-out

• District stakeholder meeting
• PSI/DHMT committee formed
• DHMT training (1 day)
• Nurse training (1 day)
• Seed net delivery
• Install safe/ health talk guide
• 1-2 visits per month
• Roll out at 3 districts per month

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Health facility model (4)Regulations

• One net per eligible health passport/ card
  (stamped)
• Issue receipt for every net sold
• Unsold nets never to leave facility
• Nurses commission 20 (12.5 US cents)
• Commission not paid until cash/stock
  reconciliation completed

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Health facility model (5)PSI resources

• 4 warehouses
• Partial use of three 5 ton trucks
• 6 land cruisers
• 12 dedicated staff
• 6 part time staff

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Health facility model (6)Current status

• 26 districts
• 437 health facilities (since 1.11.02)
• MK 50 price announced 5.11.02
• Training completed in 26 districts
• 280 DHMT staff trained
• 1832 nurses trained
• Nets supplied once per month sold in 2-5 days

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Health facility model (7)Lessons learned

• DHMT ownership essential
• Nurse incentive essential
• Cash/stock reconciliation essential
• Logistic capacity and planning essential
• Model based on leveraging the opportunity
  provided by a health professional meeting members
  of the key risk groups to promote and supply ITNs.

16
Community based model

• Product Unbranded green square net
• Target rural communities
• Distribution mechanism
• PSI/Malawi to DHMT/ local NGO
• DHMT to VHC
• Consumer price US 1.25
• Revenue US 1 (40 subsidy)
• Estimated sales 150,000 per year
• Advantages rural penetration affordable to most
• Disadvantages untargeted subsidy accountability
  difficult to ensure

17
Rate of sale since Nov 2002(national program
with subsidised nets)
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Distribution issues

• Sales constrained solely by rate of supply by
  manufacturer
• Genuine demand at current price estimated at
  150-200,000 ITN per month for at least one year
• PSI capacity to deliver to HF and community based
  models estimated at 300,000 per month
• Manufacturer has guaranteed 200,000 per month
  beginning May 2003.

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Programme efficiency

• Volume increases from 16,500 to 1,000,000 p.a
• Public per net delivered decreases from 18.35
  to 1.74
• 2003 volume figure is estimate and cost per net
  based on 1st quarter sales and costs.

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Programme Running Costs (2002) Total nets sold
374,461
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Commodity Unit Cost (2003)Total nets sold
374,461
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Cost per product delivered (2002)Total nets sold
374,461
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Cost breakdown per unit
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Cost of national subsidised programme1st Quarter
2003Total nets sold 150,847
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Cost of national programme1st Quarter 2003Total
nets sold 180,349
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Acknowledgements

• Malawis nurses
• Malawis DHMT staff
• Malaria Control Programme
• Malaria Technical Committee
• MOHP
• UNICEF
• USAID
• DFID
• WHO