[NOTE: This is an UPDATE to a case study initially published in 2009. Read the original case study for appropriate context.]

The people of Tanzania have been living with the scourge of malaria for thousands of years. They’ve been living with National Insecticide Treated Nets (NATNETS) for a little more than a decade, a program providing Tanzanian citizens with insecticide-treated mosquito nets to protect them from the mosquito-borne infection.

Since the NATNETS program was established in 2000, some 27 million nets have been distributed free of charge and more than 7.8 million have been sold at highly subsidized rates. Results suggest that they are having a major effect in reducing the incidence of malaria among the Tanzanian population.

At the same time, while NATNETS itself has always been implemented as part of Tanzanian Ministry of Health and Social Welfare’s National Malaria Control Program (NMCP), it was managed on behalf of NMCP by the Swiss Tropical and Public Health Institute (Swiss TPH) for much of that time. As of 2011, NMCP took over management responsibilities, with Swiss TPH now providing technical advice and financial support. The plan is for the program to transition to one overseen and staffed entirely by Tanzanian health officials—a slow evolution as Tanzania develops the resources and capabilities to fully take on that role.

Photo credit: Swiss Tropical and Public Health Institute, G. Kalagho

“NATNETS is a very large health program of the Tanzanian government,” notes Christian Lengeler, Ph.D., an epidemiologist with Swiss TPH who was involved in establishing the program. “It’s logical and beneficial that the Tanzanians take it over. That was the goal from the beginning.”

From Long-Standing Scourge to NATNETS Target

Malaria is caused by single-celled parasites of the genus Plasmodium, spread among humans by bites of anopheles mosquitoes. Injected into the bloodstream, the parasites invade their hosts’ liver cells and subsequently feed on and destroy red blood cells. Besides the fevers and other symptoms that come with active malaria, the disease causes anemia, spleen enlargement and general debility.

Some 216 million people were infected with malaria and an estimated 655,000 died from the disease in 2010, according to the World Health Organization. Due to lowered immune systems, children and pregnant women are considered to be especially at risk—the disease accounts for approximately 22 percent of all childhood deaths and most deaths occur among children living in Africa. In Tanzania, some 95 percent of the country’s 38 million people are considered at risk for the disease.

Born of Government, Private and Nonprofit Collaboration

Issues like malaria control have long been the subject of international interest in Tanzania. NATNETS grew out of collaboration by a range of government, private and nonprofit agencies. The fact that net distribution could be effective had been demonstrated by earlier regional programs supported by organizations as diverse as Swiss TPH (until 2010 called the Swiss Tropical Institute), the London School of Hygiene and Tropical Medicine and Population Services International.

In 2000, the Tanzanian Ministry of Health and Social Welfare, working with Swiss TPH, the nonprofit Population Services International, UNICEF and other stakeholders, developed the first national policy on treated nets and created NATNETS within the National Malaria Control Program. The goal was to distribute insecticide-treated nets (ITNs) to at least 60 percent (later increased to 80 percent) of the most vulnerable Tanzanians, especially women and infants.

In 2002 the Swiss Agency for Development and Cooperation started supporting an ITN "cell" within the NMCP to manage the program. This allowed Swiss TPH to provide staff and financial support for the management of NATNETS.

In October 2011, the leadership of NATNETS was taken over by Ministry of Health and Social Welfare epidemiologist Renata Mandike, M.D., notes Karen Kramer, who is employed by Swiss TPH as technical advisor to Mandike. The intent is for other members of the cell, all Tanzanian nationals, to train their civil service counterparts in their duties and eventually turn their responsibilities over to them.

Uniform Prices and Long-Lasting Insecticide Treated Nets

The NATNETS program encompasses all national interventions aimed at scaling-up the use of ITNs. The Tanzania National Voucher Scheme is designed to make ITNs accessible to pregnant women and infants at a highly discounted price (approximately 50 cents in U.S. dollars). And a Behavior Change Communication program is designed to educate Tanzanians about the importance of the nets.

Photo credit: Swiss Tropical and Public Health Institute, G. Kalagho

“Malaria has always been there and people regarded it as part and parcel of daily life,” Mandike says. “The challenge has been to persuade them to take care and use the nets effectively. All interventions are about behavioral change, and it takes time to get people to understand.”

“Under the original voucher program,” Kramer notes, “people paid different prices for the nets depending on where they bought them. That was changed in 2009 to ensure a uniform top-up price. In the beginning, polyester nets and insecticide were sold as bundles, with the owner responsible for treating them. And they had to be re-treated every six months.”

In 2009 the Ministry switched to polyethylene nets that are pre-treated with insecticide by the manufacturer. The insecticide in the new generation of Long Lasting Insecticidal Nets (LLINs) is good for the life of the net, which is expected to be three to five years. Today, all the nets come from one manufacturer based in Tanzania.

“Most of the project’s success has come in the last few years,” notes Mandike. In 2009 and 2010, an “Under-Five Catch-Up Program” was implemented to deliver LLINs to the most vulnerable at no cost. That was followed by a “Universal Coverage Campaign” meant to reach every sleeping space not covered by the earlier campaigns.

Eventually, the challenge will be to replace the nets as they reach the end of their useful life. “We have to ensure that we retain what we have accomplished,” Mandike says. “Net replacement is currently being discussed.”

Broad International, Interagency Support

From its inception, NATNETS has drawn support from an array of international stakeholders—United Nations agencies like the World Health Organization and UNICEF, foreign government programs, nonprofit health organizations and academic institutions. More than half has come from the nonprofit Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM).

Photo credit: Swiss Tropical and Public Health Institute, G. Kalagho

Often, a variety of sources have supported specific elements of the program. The World Bank funded a large-scale program to re-treat older nets. Funding from GFATM, the U.S. President’s Malaria Initiative and the U.K. Department for International Development has supported voucher programs for nets for pregnant women and infants. World Vision Tanzania has provided training and coordinated net deliveries. Mennonite Economic Development Associates has assisted with logistical issues since the program’s early years. Population Services International and the Communication for Malaria Initiative headed by Johns Hopkins University’s Bloomberg School of Public Health have been instrumental in designing and implementing behavioral change programs.    

The Swiss Agency for Development and Cooperation has been a crucial source of support for the program since NATNETS was initiated. The contract for the most recent phase of the ITN management program has recently been extended for a year, and will soon also cover other program aspects, such as case management, making sure drugs are available in the clinics and ensuring that people have access to them, Kramer notes.

“NATNETS has been remarkably successful,” notes Lengeler. “With nearly 35 million nets distributed, the decrease in malaria infections in Tanzania has been spectacular. One measurement is that child mortality has dropped 50 percent over 10 years.”

By Ralph Fuller