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[This article was published in 2009 and updated in May 2012. Read the update here.]

Malaria is the overall leading cause of death in Tanzania with approximately 36 of 38 million Tanzanians at risk of contracting the disease. Health care and treatment for malaria, along with decreased economic productivity and opportunity, costs the nation an estimated $119 million per year, 3.4 percent of gross domestic product. For Tanzania, malaria is not only a health issue, but a development issue.

To control malaria, which is transmitted by Anopheles mosquitoes, Tanzanians — especially pregnant women and children under five years old who are most vulnerable to the disease — are encouraged to protect themselves with insecticide-treated bed nets. NATNETS, a collaboration of government, private and nonprofit agencies, with the goal to plan and implement a national strategy to increase the use of insecticide treated nets (ITNs) in Tanzania, used the successes of partners’ past programs and utilized the roles of each organization to establish a successful and growing malaria control program.

Led by Example

To develop NATNETS, organizers reviewed results from previous bed net operations. The Kilombero Net (KINET) project operated in two districts in the Kilombero Valley from 1996 to 2000. The Ifakara Health Institute, formerly Ifakara Health Research and Development Centre, and the Swiss Tropical Institute, with support from the London School of Hygiene and Tropical Medicine, implemented the bed net distribution program. The KINET project showed an association between regular use of ITNs and a 27 percent reduction in child mortality, as well as a 60 percent decrease in childhood anemia. ITNs also proved to have a positive impact on reducing malaria in pregnant women.

KINET not only showed bed nets could control malaria under such a program; it also generated initial social marketing experience and tested an innovative voucher system. Pregnant women were given a voucher that allowed them to buy a net at a discounted price in participating shops.

In addition to KINET, Population Services International’s (PSI) Social Marketing for ITNs (SMITN) project operated in four additional regions from 1998 onward. With funding from the United Kingdom Department for International Development (DFID) and the Royal Netherlands Embassy, a classic social marketing program introduced two new brands of ITNs, including heavily subsidized nets for pregnant women. SMITN also developed and marketed subsidized insecticide re-treatment kits, a highly innovative development that offered a new method to promote net re-treatment.

In October 1999, a group of stakeholders from the public and private sector met to discuss the success of these projects and the urgent need for a national ITN policy in Tanzania. As a result of this meeting, in 2000, the Ministry of Health and Social Welfare (MoHSW) of Tanzania commissioned the development of a national ITN policy. This policy was developed by the National Malaria Control Program, the UNICEF and the Swiss Tropical Institute, discussed by national stakeholders in August 2000, and approved by the MoHSW in December of that same year, thus creating a national strategic program for scaling up the use of ITNs in Tanzania called NATNETS.

Establishing ITN Policy in Tanzania

With the formally established national policy, SMITN became a national program and was renamed SMARTNET in 2002. SMARTNET went further than the original program. It dropped procurement and distribution of its own subsidized ITN brand, called Njozi Njema, and started supporting brands owned by the local net industry. The private sector was brought more into the partnership.

While KINET and SMITN had inhibited the development of local distribution networks because the commercial sector could not compete against subsidized products, net manufacturers could now rapidly develop their own brands. Under SMARTNET, a memorandum of understanding was established with net manufacturers. They would be provided with free insecticide kits if they agreed only to sell nets bundled with kits. Manufacturers and wholesalers were provided with transport subsidies to ensure nets were available in remote areas, and retailers were also recruited to participate by stocking nets.

SMARTNET, like SMITN, included an important behavior change component that stressed the importance of nets in preventing malaria and encouraged Tanzanian residents, especially pregnant women and children, to use nets diligently. The campaign messages were released through radio, TV and print marketing, as well as rural films, road shows, posters and roadside signs. Radio proved to be the most effective marketing tool. Multi-brand commercial advertising also increased demand.

In 2003, the government of Tanzania, the Swiss Agency for Development and Cooperation (SDC) and the Swiss Tropical Institute, acting as SDC’s executive agency, partnered to develop an ITN cell within the National Malaria Control Program. The Swiss Tropical Institute provided experienced staff and technical support to this cell, and SDC provided funding via the institute. From then on, the ITN cell would be responsible, as a part of the National Malaria Control Program and, hence, the MoHSW, for facilitating and coordinating the NATNETS program’s overall management and fundraising.

The ITN cell organized a NATNETS Steering Committee to provide guidance for and oversight of the program in general, and the ITN cell specifically. The committee is chaired by the chief medical officer and includes the director of preventative services, the national malaria control program manager, the ITN cell team leader and representatives from the Swiss Tropical Institute; the DFID; the Dutch embassy; United States Agency for International Development, under the President’s Malaria Initiative; Population Services International; the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria (GFATM); Local Fund Agent (PWC); UNICEF; and the World Health Organization (WHO). The committee meets quarterly, more often if necessary.

Membership of the Steering Committee changes periodically to reflect the changes in the donor partnership. With the launch of the President’s Malaria Initiative and the World Bank’s Malaria Booster Programme, both organizations were invited to join the Steering Committee, while the UK’s DFID discontinued its membership upon the conclusion of the SMARTNET program.

The Tanzanian National Voucher Concept

Don de Savigny of the Swiss Tropical Institute came up with the idea to create a voucher system to distribute insecticide-treated nets. De Savigny, along with Alastair Unwin of the UK’s DFID and the National Malaria Control Program, developed a proposal for the plan and brought it to NATNETS partners.

In June 2003, after successfully securing the first grant funded by the GFATM, the MoHSW contracted Mennonite Economic Development Associates (MEDA) to design a voucher system for the distribution of insecticide-treated nets. Following the design of the Tanzanian National Voucher Scheme (TNVS), MEDA was contracted to implement the program.

MEDA, the logistics contractor for TNVS, which has been involved in the insecticide-treated net sector in Africa since the early 1990s, prints and delivers vouchers at the national level through the Tanzanian health system via 4,432 clinics.

Initially, every pregnant woman received a voucher at the time of her routine checkup. In 2005, the President’s Malaria Initiative joined NATNETS to fund an infant voucher, which was introduced the following year. Vouchers are given to a child’s mother or caregiver when a child is brought to a clinic for measles vaccination at nine months of age.

Pregnant women and mothers can use vouchers in any participating shop for a $2.50 discount on a treated net. Retailers, in turn, redeem vouchers for more nets from wholesalers. Wholesalers are reimbursed the value of nets by the project or by manufacturers, in the form of more nets. Four net manufacturers, A-Z Textiles, Sunflag, Moshi Textile and TMTL, participate in the TNVS, and 250 wholesalers and 6,900 retailers are registered by MEDA to accept TNVS vouchers. To date, more than 4.9 million vouchers have been redeemed.

Contractual partners, who were originally selected by the government of Tanzania’s Central Tender Board under competitive tender in 2003 and 2004, implement the TNVS. MEDA manages the logistics of the program. Net-use training and promotion is handled by World Vision Tanzania, with assistance from CARE Tanzania during the first 18 months. The London School of Hygiene and Tropical Medicine and the Ifakara Health Institute oversee monitoring and evaluation. A financial audit is conducted by KPMG.

Playing Catch-up

In 2007, after much debate, ITN stakeholders decided to launch a new campaign, the Under Five Catch-up Campaign (U5CC), to bring long-lasting insecticidal nets to every child in the country. The new campaign was made possible through an extension to the Round 1 grant to Tanzania from the GFATM. In addition, the World Bank gave a $25 million soft loan to support the campaign, as well as a National Net Re-treatment Campaign in 2007. As a result, the World Bank joined the NATNETS Steering Committee.

The U5CC received additional support from the President’s Malaria Initiative and UNICEF, which received funding for the program from the U.S. charity Malaria No More. The coordination of the U5CC rests within the ITN cell, on behalf of the MoHSW, through policy, grant management and supervision, and contractor oversight.

For this campaign, which is currently under way, 7.2 million longlasting insecticidal nets made in Tanzania (Olyset™) are distributed to families with children who are under five years old. The nets remain treated with insecticide for at least five years. Because the manufacturer is local and responsible for distribution down to the village level, local logistics are well-handled.

On a district level, the prime minister’s office and regional and local governments are responsible for the implementation of the program. Village and ward executive officers register eligible children and organize distribution locally. They follow training by World Vision Tanzania and coordinate net deliveries through MEDA, who works with A to Z Textile Mills, the net manufacturer.

Other implementing contractors include, CARE Tanzania, the Ifakara Health Institute, the London School of Hygiene and Tropical Medicine, and KPMG. PSI and The Johns Hopkins Bloomberg Center for Communication and Programmes implement a supporting behavior change campaign.

Maintaining a Multi-Sector Partnership

The NATNETS Steering Committee manages the program at the policy and strategy level and meets quarterly. Members also hold ad hoc meetings as issues arise. On the implementation level, contractual partners meet monthly to discuss project development. Additionally, a quarterly publication, NATNETS News, provides a link to partners and Tanzanian stakeholders.

Government participation in the partnership was critical to the program’s success. The Tanzanian government supported the public-private partnership approach, exemplified in the SMARTNET program. It also supported NATNETS submission of the Global Fund Round 1 proposal that secured funding for the TNVS. Government also played a key role in the implementation of TNVS, by distributing vouchers through reproductive and child health clinics.

An important element of the partnership’s success is the established understanding of the need for monitoring and evaluation. Ifakara Health Institute and the London School of Hygiene and Tropical Medicine fulfill this role since joining the partnership in 2004. At first, members were uncomfortable with being evaluated but were persuaded when they realized monitoring helped determine best practices.

For example, the evaluation of delivery strategies was taken to NATNETS stakeholders and discussed by Steering Committee members to determine which approach held the most promise for the program’s future.

Clear lines of communication among partners were crucial to the partnership’s success. Strategic and implementation issues are discussed regularly and openly by partners to ensure each has his or her voice heard on matters relating to the project’s operations and future planning. Recognizing each partner’s expertise and finding value in his or her perspectives is crucial to the success of this large-scale partnership.

Moving forward, NATNETS is focused on two campaigns, the U5CC, taking place now and scheduled for completion in early 2010, and the Universal Coverage Campaign, scheduled for the remainder of 2010. The goal of the Universal Coverage Campaign is to provide a long-lasting insecticidal net for every sleeping space in mainland Tanzania by distributing more than 14 million nets. In the last quarter of 2009, long-lasting insecticidal net vouchers will be introduced to pregnant women and infants and will provide a continuing means to deliver them to newly pregnant women and infants.

Organizers are aware that demand for new nets will decline in the immediate aftermath of the Universal Coverage Campaign, and it is not known how this will affect the willingness of retailers to stock nets as they try to anticipate changes in the marketplace.

In the long-term, as existing nets wear out, there will be an extensive consultative process conducted zone by zone among all stakeholders to identify policy and distribution options for distributing new nets and laying the foundation for a future “keepup” strategy.

By Ashley Mastandrea