Ghana LLIN e-Coupon Pilot Process Evaluation November-December 2013

Final report submitted to Networks 31 January 2014

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Acknowledgments The evaluation team would like to thank all those who have generously given their time, experiences and expertise in guiding this work. In particular, the evaluation team would like to thank Sam Seddoh for providing his valuable inputs, as well as individuals from other organizations who were willing to be interviewed as part of this evaluation. These include representatives from NetWorks Ghana, MEDA, the Ghana National Malaria Control Program, the Ghana Education Service Schools Health Education Program Unit, the Regional Public Health and Education Offices (Koforidua), USAID, DFID and others interviewed for the process evaluation.

Disclaimer This study is made possible with the generous support of the American people through the United States Agency for International Development (USAID) under the terms of USAID/JHU Cooperative Agreement No. GHS-A-00-09-00014-00. The contents are the responsibility of Karen Bulsara and Justice Ajaari of Tropical Health LLP and do not necessarily reflect the views of USAID or the United States Government.

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Table of Contents

EXECUTIVE SUMMARY.............................................................................................................................. 5

INTRODUCTION ........................................................................................................................................ 8

BACKGROUND .............................................................................................................................................. 8 THE GHANA LLIN ECOUPON PILOT ................................................................................................................ 10 PURPOSE OF ASSESSMENT ............................................................................................................................ 11 KEY INFORMATION AND INDICATORS TO COLLECT ............................................................................................. 11

METHODOLOGY AND LIMITATIONS ....................................................................................................... 13

EVALUATION TEAM STRUCTURE AND GENERAL APPROACH ................................................................................ 13 DATA COLLECTION METHODS ....................................................................................................................... 13 DATA ANALYSIS METHODS ........................................................................................................................... 15 LIMITATIONS .............................................................................................................................................. 15

FINDINGS ................................................................................................................................................ 16

PREPARATION FOR THE PILOT AND ADVOCACY .................................................................................................. 16 E-TECHNOLOGY ENVIRONMENT .................................................................................................................... 16 LLIN ECOUPON SCHEME PROCESS ................................................................................................................. 18 ECOUPON ISSUERS ...................................................................................................................................... 19 ECOUPON SELF-ISSUE .................................................................................................................................. 22 ECOUPON REDEMPTION OUTLETS .................................................................................................................. 22 MAPPING USING GPS ................................................................................................................................. 24 PERFORMANCE OVER THE DURATION OF THE PILOT (23 SEPT – 3 DEC) ................................................................ 26 CUSTOMER FEEDBACK ................................................................................................................................. 29 SCHOOLS PROGRAM .................................................................................................................................... 29 EMPLOYER PROGRAM .................................................................................................................................. 31 DISTRIBUTION AND SUPPLY CHAIN PRICING ..................................................................................................... 32 OPERATING ENVIRONMENT / PARTNERSHIPS ................................................................................................... 33 LLIN DEMAND CREATION / PILOT PROMOTION ............................................................................................... 34 ACCEPTABILITY / CONTINUED SUPPORT .......................................................................................................... 36 COST OF THE PILOT PROGRAM ....................................................................................................................... 36

SUMMARY AND CONCLUSIONS ............................................................................................................. 38

PROGRAM EFFICIENCY ................................................................................................................................. 38 PROGRAM EFFECTIVENESS ............................................................................................................................ 40 CONCLUSION .............................................................................................................................................. 43

RECOMMENDATIONS ............................................................................................................................. 45

ANNEXES ................................................................................................................................................. 47

ANNEX I: SCOPE OF WORK .......................................................................................................................... 48 ANNEX II: WORK PLAN ................................................................................................................................ 52 ANNEX III: DATA COLLECTION TOOLS ............................................................................................................. 54 ANNEX IV: SOURCES OF INFORMATION........................................................................................................... 62 ANNEX V: TABLES FOR ECOUPON ISSUE BY ISSUE POINT AND ECOUPON REDEMEPTION BY OUTLET .......................... 65 ANNEX VI: SCRIPTS FOR RADIO ADVERTISEMENTS AND SELECTED AIRTIME SCHEDULES (OF 4) ................................. 67

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Acronyms ANC Antenatal Clinic API Application Programming Interface BCC Behavior Change Communication CEO Chief Executive Officer CIC Community Information Centre DFID Department for International Development (UK AID) DHS Demographic and Health Survey e-Coupon Electronically-generated Coupon (number) EPI Expanded Program of Immunization Gh c Ghana Cedi (currency) GDHS Ghana Demographic and Health Survey GDP Gross Domestic Product GHS Ghana Health Service GPS Global Positioning System GSMF Ghana Social Marketing Foundation ICT Information and Communications Technology ITN Insecticide Treated Net JHU CCP Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs JICA Japan International Cooperation Agency LLIN Long Lasting Insecticidal Net LMIC Lower Middle Income Country LPMs Live Presenter Mentions (form of radio promotion) MC Malaria Consortium MEDA Mennonite Economic Development Associates MDGs Millennium Development Goals MIC Middle Income Country MICS Multiple Indicator Cluster Survey MOH Ministry of Health MTN Mobile Telephone Networks – Cellular Telecommunications Company NGO Non-Governmental Organization NMCP National Malaria Control Program, Ghana ODA Overseas Development Aid P2, P4,P5 Primary 2, Primary 4 and Primary 5 (equivalent to Grade in Elementary school) PMI President’s Malaria Initiative (US Fund for Malaria) SHEP Schools Health Education Program Unit (of Ghana Education Service) SMS Short Message Service (mobile text messaging service) TNVS Tanzania National Voucher Scheme UNICEF The United Nations Children’s Fund USAID United States Agency for International Development VREL Volta River Estates Ltd (Local Banana Plantation)

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EXECUTIVE SUMMARY By the end of 2012, Ghana had delivered over 12 million Long Lasting Insecticidal Nets (LLIN) to households through its universal coverage campaign and went on to adopt a continuous distribution approach, after the mass campaigns, to sustain high levels of LLIN coverage. However, sales through the private sector channel have lagged behind, as there is yet to be a clear strategy to support the activity. The NetWorks project designed and implements an eCoupon Pilot Program through the private sector in Koforidua, the capital of the Eastern Region of Ghana, due to run for six months (August 2013 to January 2014) with the aim to inform possible approaches for private sector involvement in LLIN distribution. The eCoupon pilot had multiple aims: to create an eCoupon platform with the capacity to manage LLIN subsidies of differing levels, from multiple donors, to a variety of target populations; to create demand for subsidized LLINs in Koforidua and in selected workplaces; and to demonstrate a cost effective public-private-partnership. The Networks project team commissioned a Process Evaluation of this pilot and this reports covers the evaluation findings. The process evaluation team consisted of an international private sector specialist and a Ghanaian researcher and the evaluation was carried out between 23rd November and 13th December 2013, during the second half the pilot project period (70% of pilot period elapsed). The methodology entailed three data collection methods to acquire the program implementation process data: a review of key program documents; an analysis of computerized transactions for eCoupon issue and redemption; and interviews with those participating in the program about their experiences. The pilot was able to demonstrate that the process of eCoupon issue and redemption is a technology which can be implemented in Ghana. The e-coupon pilot was also successful in: reaching different population segments (Koforidua residents, school children and employees); delivering varied levels of subsidy to these different segments; and utilizing a mix of subsidies from different donors, including employer contributions. The actual net sales achieved over the duration of the pilot were, however, very low, with only 633 nets sold between September and December, which is far short of the 20,000 target over six months (8,800 targeted for the 11 weeks of the pilot to date) planned at program inception. However, this was an unrealistic target figure, particularly since the pilot is so short in duration; is being conducted so soon after mass campaigns in the pilot area; and whilst continuous distribution programs are still offering free LLINs through ANC and primary schools. It is essential that overlap with any existing programs in schools is avoided through strategic planning of the roll-out closely coordinated with any other public sector LLIN initiatives. Current LLIN ownership and intra-household saturation is high and hence the demand for LLINs is low and there is still an expectation that LLINs should be free. Although calculated from a very low base, a redemption rate of 56% was achieved. This is a positive result, especially when compared to the Tanzania National Voucher Scheme, which has been running for nearly 10 years, and achieved a redemption rate of 62% in the first year of their eVoucher pilot. However, there are a number of issues that the process evaluation drew up which will need careful consideration and potential redesign when considering a scale-up. A key finding was that there is a need for much stronger advocacy for private sector initiatives and for the eCoupon program. The National Malaria Control Program (NMCP) buy-in was very weak and the program had not engaged sufficiently with key stakeholders to gain local understanding and ownership. The scale-up will have to follow due process as indicated by the NMCP and create a much stronger platform of dialogue

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between public and private sectors. However, advocacy at local level within Koforidua was far better. Both Health and Education officials were involved in design and were accepting of the program. As mentioned, the e-technology platform appears to be working successfully and the process has been well received by participants in the community. The only drawbacks are patchy and inconsistent network coverage levels and mobile phone signals in Ghana. The eCoupon process has received some criticism as cumbersome, having to use two different locations for issue and redemption. The implementing team were cognizant of this criticism and attempted to recruit a ratio of 1:1 (issuer : redemption outlet) to alleviate the burden of additional travel between locations and will also attempt to trial self-issue, where consumers will use their own phones to obtain eCoupons. Initial respondent feedback for this idea was not positive, however. A major hurdle to overcome, which will have to be addressed in the scale–up, is that Ghana does not appear to have a strong “net” culture yet (i.e. both in terms of net use and demand for nets). There is a need for heavy and sustained social and behavior change communication and LLIN demand generation for net purchase and use. The majority of Koforidua respondents questioned stressed that more promotional activity was required to generate awareness about and demand for LLIN and the eCoupon scheme. Although generating some awareness of the Donkomi promotion, pilot promotional activities proved unsuccessful in sustaining awareness and generating LLIN redemption, particularly the launch activation activity. In addition, the low weight of radio advertising on local channels proved ineffective. The schools program offered the best issue and redemption rates, as would be expected from this captive audience. The employer program generated a redemption rate of 60%1. It is believed that this could increase to nearer 90% when supply problems encountered during the pilot are overcome. With regard to implementing partners, the key partner - the private sector distributor - was not wholeheartedly behind the program. Currently, only one active LLIN distributor remains in Ghana and they complained of making a loss with this program and further, are not convinced that LLINs are a viable retail product at this time. eCoupon issuers are also a potential weak point in the program as they are offering their services freely in a spirit of volunteerism. This may not be sustainable and is a key reason why the self-issue is being trialed. Nearly all redemption outlets received LLINs on 100% credit and so did not complain that LLINs were not selling. They reiterated that demand was low and more promotion was necessary. These are all pressing issues, which will require attention and re-design during scale-up. The terms of reference for this process evaluation requested that an average cost per net delivered to beneficiary be calculated; this could only be estimated and came to approximately $200 per net sold. While this shows the pilot to be cost–inefficient at the moment of the evaluation, it is obvious this is because this was an investigative pilot and new methods were being trialed; equally, the same sunk costs could deliver many more nets if the pilot scope had been widened geographically. This estimate should therefore not be taken as a reflection of the cost per net sold that might be obtained at the end of the pilot nor that could be obtained through a similar program implemented at scale. The NetWorks team will have to build the case for this program, make projections for the cost per net obtainable at scale (separating start-up from recurrent costs) and particularly stress the cost savings achievable through this methodology (potentially using TNVS case studies). This is a major concern for the NMCP. The primary reason given for the previous voucher program in Ghana being stopped was top-heavy management agency fees. The cost savings of the electronic system need to be well

1 Note that all results are up to 3 December 2013 except for the employers program for which results up to 19th January 2014 are evaluated

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articulated and shared amongst key stakeholders, particularly NMCP and the LLIN Steering Committee. Recommendations are detailed for the program scale-up, which stress many of the points brought up in the findings narrative. There are warning signs which must be adhered to, particularly since many of the issues mirror those that were detailed in the 2012 article articulating the reasons for the success and failure of voucher programs in both Tanzania and previously in Ghana2. Advocacy for this program needs to be stepped-up. The private sector must be re-engaged and new distribution channels must be considered. Indeed, the overall concept and role of the commercial sector needs further discussion and acceptance amongst stakeholders in Ghana and particularly the NMCP, before a nation-wide eCoupon program can be successful. Behavior change communication as well as promotional campaigns are essential to stimulate awareness and demand for LLIN purchase. This new social norm has to be created and will take time and investment. The current environment in Ghana is not favorable to a program of this nature and with donor funding likely to be drastically cut in the next five years as Ghana enters a new status of Middle Income Country, this adds to the pressure for a potential donor funded scale-up program to perform within a limited time frame3.

2 Introducing vouchers for malaria prevention in Ghana and Tanzania: context and adoption of innovation in health systems; de Savigny, D. et al; Health Policy and Planning 201227: iv34-iv42 3

The Ghana UK government Department For International Development (DFID) Health Advisers informed the evaluation consultants that they are likely to fund the scale-up of this pilot for a period of three years starting early 2014.

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INTRODUCTION

Background A brief history of Insecticide Treated Nets (ITN) distributions in Ghana is described below, as taken from the Ghana Multiple Indicator Cluster Survey (MICS), 2011.

By the end of 2012, Ghana went on to adopt a continuous distribution approach after the mass campaigns to sustain high levels of LLIN coverage. The four main channels for continuous distribution are through ANC, EPI clinics, two targeted classes in primary school annually, and private sector sales at full and subsidized prices. Distribution through ANC, EPI and schools has begun and is being scaled up. However sales through the private sector are lagging behind as there is yet to be a clear strategy to support that activity.

Box 1: Brief History of ITN Distribution in Ghana – 2002-2012 The MICS 2011 data on ITN ownership and use will be best understood if Ghana’s recent history of ITN distribution is known. From 2002 to 2009, the Ghanaian Ministry of Health (MOH) embraced a mixed model of ITN distribution, in which subsidized distribution through the public and private sector, workplace and Non Governmental Organizations (NGOs) distributions, and full-cost sales all contributed. This resulted in 42% of ITN ownership (as reported in the 2008 Ghana Demographic and Health Survey (GDHS)). In order to promote the ownership of mosquito nets, the government of Ghana, since 2002, has implemented a tax waiver policy on the importation of mosquito nets into the country. Development partners contributed by providing ITNs for distribution at subsidised costs to pregnant women and children under five in disadvantaged areas of the country through routine public health services. During 2002-2010, the National Malaria Control Program (NMCP), United States government President’s Malaria Initiative (PMI), World Bank, UNICEF and Global Fund between them provided enhanced support for subsidized ITN distribution in all regions except Greater Accra. Japan International Cooperation Agency (JICA) continued such support in Upper West through 2011. In 2010, Ghana Health Service, led by the NMCP, and with the support of development partners, began focusing on a “catch-up” strategy of implementing free mass distribution campaigns with the goal of achieving universal coverage of LLINs in all ten regions by 2012. This campaign provided free LLINs in door-to-door, hang-up exercises nationwide, distributing approximately 14 million LLINs over two years. The LLIN hang-up exercises were carried out through a program of door-to-door visits by community volunteers in each region. The door-to-door, hang-up approach was tested in May 2010 in the Northern Region, through a campaign which targeted just children under five and pregnant women. The remaining campaign targeted universal coverage of the general population, defined as one net per every two persons. The NMCP goal for these campaigns was to achieve 75% of households owning at least one LLIN. At the time of the 2011 Ghana MICS survey data collection (Sept 15-Dec 15, 2011), universal-coverage campaigns had been completed in the Eastern, Volta, and Western regions. Central Region began its campaign toward the end of that period. The remaining regions had their campaigns in 2012, i.e. after the MICS data had already been collected.

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This gives a picture of the environment within which the eCoupon pilot was implemented. The free net culture is still predominant and the Ghanaian distributers had been abandoned when mass campaigns required institutional purchase from international manufacturers by NMCP for high volume, which were found to have a fundamental effect on the results of the eCoupon pilot program. Table 1 presents a brief consideration of political, economic, social and technological (PEST) operating environment for the eCoupon pilot.

Table 1: PEST Analysis: A Brief Overview of the operating environment within Ghana

POLITICAL • Stable democratic government, although growing

unrest at widening inequalities

• Due to changes in Ghana’s economic status, donor funding is declining. DFID likely to withdraw funding in next five years. USAID will not fund private sector distribution methods in malaria under their current Malaria Operational Plan.

• Malaria is a priority intervention in the health sector.

• Active NMCP

• Cross-sectoral support in education for ITN schools programs

• History of innovative responses to malaria programming – have trialled vouchers in the past

• History of external agencies interference in malaria programing resulting in lack of consistent focussed programming being sustained

ECONOMIC • Ghana has Lower Middle-Income Country (LMIC)

status. On target to achieve Middle Income Country (MIC) status by 2015

• MIC status will diminish Overseas Development Assistance (ODA) and could have impact on achievement of Millennium Development Goals (MDG)

• Gross Domestic Product (GDP) growth slowing to 6% in 2013 (down from 15% in 2011 following start of local oil production). Inflation is at 11%

• Medium term growth prospects boosted by oil exports. Risks to continued growth from mismanagement of oil revenues, failure to tackle deficits & over reliance on agriculture.

• Major urban markets & distribution systems are well developed for the whole country. But commercial net distribution virtually stopped during mass campaigns.

• Imported Long Lasting Insecticidal Nets (LLIN) are free of import duty

• Only one functional LLIN importer/distributor active in Ghana (i.e. Agrimat) at time of pilot.

• Limited Social Marketing of nets from 1998- 2002. No strengthening of private sector through this mechanism.

SOCIAL • Net-use culture is low. Only 34% of households

seen with ITN hanging compared to 46% owning any ITN (MICS, 2011)

• Rural households more likely to own a net (63%) than urban households (41%) (MICS 2011)

• Need for large-scale BCC campaigns to reinforce consistent use of nets

• Secondary School Policy requires all first year student intake to bring a net to boarding school

• Primary schools participating in free net distribution

TECHNOLOGICAL • No local LLIN production – reliance on imports

from international manufacturers

• Good, but variable mobile phone networks, with at least six major providers

• Penetration of mobile phone use approx. 63%4

• Competent Short Message Service (SMS) platform management in Accra with capacity for expansion

4 http://www.modernghana.com/news/443415/1/mobile-penetration-cross-100-in-ghana.html

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The Ghana LLIN eCoupon Pilot

The NetWorks project is a five-year, USAID-funded global project to improve and establish sustainable access to and use of Long Lasting Insecticidal Nets (LLINs). The Project is led by Johns Hopkins University Center for Communication Programs (JHU-CCP) and in partnership with Mennonite Economic Development Associates (MEDA) and Malaria Consortium (MC). NetWorks is currently implementing a pilot project through the private sector in Ghana to inform possible approaches for private sector involvement in LLIN distribution. This pilot scheme uses an eCoupon system to offer discounts to specific consumer groups on the purchase of LLIN. The system adapts the mobile-phone-based platform developed by MEDA for the Tanzania National Voucher Scheme (TNVS) to offer multiple donor sources of subsidy, variable amounts of subsidy offered to specific segments of the consumer population, and product variety available to the consumer. The pilot area is Koforidua, approximately 60 km from Accra (see Figure 1 below) and is a small commercial town with a population size of approximately 200,000 people.

Figure 1: Map of Ghana with pilot area

The rationale for the eCoupon program is to contribute to the maintenance of universal coverage, following mass campaigns, by: stimulating a sustainable retail supply chain; placing a subsidy in the hands of the consumer (which can be targeted to specific consumers, with differing levels of subsidy); drawing demand into retail shops and allowing inventory to be available to everyone, not just coupon recipients; allowing choice for consumers; and stimulating competition amongst suppliers. Further, cost sharing is important, since public health cannot bear the burden of LLIN supply indefinitely; and

Koforidua, in Eastern Region. Site of Pilot Project

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this method requires consumers to make some effort to obtain the LLIN, which by some is believed to increase the likelihood of use,5 although the evidence on the issue is somewhat ambiguous. Specifically, the objectives for this pilot eCoupon program are to • Create an e-coupon platform with capabilities of efficiently managing subsidies from multiple

donors, to a variety of target populations, with differing levels of subsidies for specific targeted populations.

• Create demand for subsidized LLINs in Koforidua and in the selected workplaces • Demonstrate a cost effective public private partnership to reach targeted consumers with

different levels of subsidies. The pilot is designed to reach three different targets with varying levels of subsidies for LLINs. • The general population in Koforidua, a town in the Eastern region of Ghana with a population of

about 200,000, receiving varying levels of subsidy. • Workers of two selected large employers based in two separate locations, receiving varying levels

of subsidy. • School children in grade 4. School children will receive 100% subsidy, by determining with the

supplier a previously negotiated Cedi-denominated “manufacturer’s suggested retail price” that includes a retailer mark-up.

It is intended that the results from this pilot will inform the scale-up of the e-coupon subsidy program in Ghana, as well as motivate other malaria endemic countries to adopt the strategy.

Purpose of Assessment The consultants have been engaged to (see full Scope of Work in Annex I) • Conduct a process evaluation for the e-coupon program to assess whether the program

objectives have been achieved • Produce a final report that:

o describes the current functioning of the e-coupon system, identifying strengths and weaknesses

o makes recommendations for improving or streamlining the processes o makes recommendations for key considerations as the program is scaled up.

Key Information and Indicators to collect The consultants were requested to collect the following information and indicators: 1. Document program efficiency in terms of:

a. Total numbers of LLINs distributed to identified target beneficiaries; b. Average cost per net delivered to a beneficiary, as well as individual cost components along

the supply chain; c. Time and effort required on stakeholders’ part (retailers, coupon issuers,

manufacturer/distributor, recipient) to participate in the program; d. Describe challenges, bottlenecks and other hindrances from stakeholders’ perspectives that

impact the smooth running of the program 2. Document program effectiveness in terms of:

5 Jerry Quigley, MEDA, interview, December 2013

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a. Proportion of selected target populations reached through this system, based on administrative data;

b. Redemption rates of coupons issued, by target population c. Willingness of participants in the system (coupon distributors, LLIN retail distributors, LLIN

wholesale distributor(s), donors and beneficiaries to continue participation; 3. Develop recommendations for scale-up, based on problems encountered and potential

solutions/changes needed.

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METHODOLOGY AND LIMITATIONS

Evaluation Team Structure and General Approach The evaluation team consisted of an international Private Sector Specialist and lead, Karen Bulsara, responsible for evaluation methodology development, stakeholder interviewing, strategic review and reporting; and a Ghanaian researcher, Justice Ajaari, responsible for field interviews of all implementing partner stakeholders in Koforidua. At the beginning of the assignment a detailed work plan (see Annex II) was discussed with and approved by the Networks team. Data collection tools (see Annex III) were developed, reviewed by the Networks team and finalized at the beginning of the consultants’ Ghana trip.

Data Collection Methods Three data collection methods were utilized to acquire the program implementation process data: 1. Review of key program documents (see Annex IV for a full list of documents reviewed).

2. Analysis of data collected in the program management process and captured by either the

computerized transactions, such as the number of coupons issued by coupon distributors, number of coupons redeemed by each LLIN distributor, the monetary value of the payments to each LLIN distributor; or by routine reporting such as the number of coupons/nets delivered to each coupon/LLIN distributor through the course of the pilot study.

3. Interviews with those participating in the program about their experiences. This includes: a. Private sector donors (international donors and participating employers) b. Pilot implementation staff (MEDA, NetWorks Ghana) c. LLIN wholesale distributer(s) d. Registered coupon issuers e. Registered retail outlet owners f. Consumers

i. Employees ii. General population

iii. School children’s parents in targeted classes

In these interviews donors, distributors, and retailers were asked how they perceived the program in terms of benefits to themselves, to their customers/clients/employees, whether they would continue to participate in such a program in the future, and why or why not. They were asked about problems they encountered in using the system, and what recommendations they would make for an improved program. During interviews with consumers they were asked about their perceptions of the program, what amount they expected to pay to get a net, what amount they actually paid, and any challenges or confusion they experienced in the process of obtaining a subsidized net.

Interviews used a discussion guide or questionnaire format, with some opportunities for short answer narrative responses. The final number of interviews to be conducted was agreed with the Networks team and actual interviews conducted were as presented in Table 2 below (See Annex IV for full List of persons interviewed):

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Table 2: Interviews planned and undertaken during process evaluation Interviewee Category Location Stakeholder Universe Interview method Duration Planned Completed

National Government Officials Accra Ministry of Health Malaria Program 2 In-depth interview 1 hour 2 2 Ministry of Education 1 In-depth interview 1 hour 1 1

International Donors Accra USAID/PMI 1 In-depth interview 1 hour 1 1 DFID 1 In-depth interview 1 hour 1 1

Private Sector Plantation Accra VREL Banana Plantation CEO 1 In-depth interview 1 hour 1 1 Dole Pineapple Plantation CEO 1 In-depth interview 1 hour 1 0

Pilot Implementation Staff Accra NetWorks 2 In-depth interview 1 hour 2 2 MEDA Project Coordinator 1 In-depth interview 1 hour 1 1 MEDA HQ staff 4 Email questions 1 hour 4 4

Partner LLIN Distributor Accra Agrimat 2 In-depth interview 1 hour 2 2 Technology Platform Partner Accra SMS Ghana 1 In-depth interview 1 hour 1 1 Promotions Company Accra Multiple Concepts 2 In-depth interview 1 hour 2 2

Local Government Officials Koforidua Regional Health authorities / Malaria Program

1 Interview 30 mins 1 1

Regional Education 1 Interview 30 mins 1 1

Workplace Employees Border region Banana Plantation 1 1 In-depth interview 1 hour 1 1 Banana/Pineapple Plantation 2 1 In-depth interview 1 hour 1 1

e-coupon Issuers Koforidua 24 Questionnaire 30 mins 18 12 Private Health Clinics 9 4 4

Hospitals 2 1 1 Community Info Centres 2 2 2

Mobile Phone Vendors 4 4 4 Schools 6 4 3

Post office 1 1 1 e-coupon Promotional Team Koforidua 10 Questionnaire 30 mins 4 3 Retail Redemption Outlets Koforidua 27 Questionnaire 20-30 mins 21

Pharmacies 8 5 7 Chemical Shops 11 6 8

Supermarkets/corner shops 5 4 3 High Schools 3 3 3

Target Consumers General Population Koforidua 633 Questionnaire 20-30 mins 20 30

Plantation 1 Employees Border region 15 Questionnaire 20-30 mins 5 10 Plantation 2 Employees Border region 15 Questionnaire 20-30 mins 5 0

Parents of school children Koforidua 20 Group Meeting 60-90 mins 8-10 in 1-2 mtgs 5 Total 767 109-129 139

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Data Analysis Methods The data has been compiled and written up here as a narrative report. The numbers of respondents gathered for interview were not sampled representatively; therefore the analysis of the interviews data is qualitative in nature rather than quantitative. The results here give indications of the pilot program and cannot be seen as definitive – it is expected that such analysis would be provided by a full end-of pilot evaluation.

Limitations There were difficulties in accessing members of the general population who had participated in this program. With limited time and a limited number of actual redemptions, the consultants were not able to conduct exit interviews with members of the public. However, the program had collated a number of mobile phone numbers of people who had participated in the scheme and the evaluation researcher was able to call them and conduct an interview with them over the phone. This was not ideal, as a data collection method, but the consultants were able to gain some insights into the process from a consumer perspective. New outlets were being recruited during the process evaluation, including a school. These outlets were joining the program late, but it gave an opportunity for the process evaluation team to witness the recruitment process. However, the two employer program plantations were only just beginning their eCoupon activity in December and so a full picture could not be gained for this initiative. The cost per net delivered to beneficiaries could only be estimated and insufficient data was made available to analyze costs along supply chain.

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FINDINGS

Preparation for the pilot and advocacy The project was conceived by JHU-CCP/MEDA and appeared to be managed primarily by senior staff from their respective headquarters offices. The operational team on the ground consisted of one Project Coordinator, who was recruited end of August. The latter was not networked into NMCP or donor circles and as such these influential stakeholders were not well informed about the pilot. Indeed the NMCP Medical Entomologist who chairs the ITN Steering Committee only met the Project Coordinator for the second time during this process evaluation and complained that NetWorks staff had not been present at the Steering Group Meeting in November to introduce and explain this pilot program, despite been specially invited to do so. The NMCP Manager knew very little about the pilot and indeed felt strongly that no scale-up program would ensue after such a short pilot, conducted in just one town. The Chair of the ITN Steering Committee was more accommodating to the idea, but stated that there had been insufficient information given to NMCP and Steering Group stakeholders regarding this project. However, there is stronger buy-in from Ghana Health Service and Education Directorate in Koforidua, both of which were involved in set-up and on-going support for the program. Regular reports about the pilot’s progress were asked for by both regional stakeholders. As soon as the Project Coordinator assumed duty in late August 2013, he started recruiting issuers, redemption outlets, schools and employers. This is a full time exercise with very little additional time for Accra lobbying and advocacy with NMCP. The project team agreed with the suggestion that, when considering a scale-up, positioning of a field coordinator is necessary within the project area, rather than being based in Accra and requiring travelling out to the project site; local knowledge of the implementation area and relationship building with local stakeholders is essential. It is recommended that at least another Project Coordinator position based in Accra be created to lead the facilitation of the public-private partnership building.

E-Technology Environment

The Total Cellular/Mobile Voice Subscriber Base in Ghana as at November, 2012 stood at 25,344,7456.

MTN maintains its position as the market leader with a subscriber base of 11,615,801 representing 45.33% of total market share.

Vodafone's subscriber base is growing at 5,175,377 which represent 20.20 % of total market share.

The Tigo subscriber base is decreasing, closing at 3,673,934 which represents 14.34 % of the market while Airtel increased its subscriber base to 3,132,615 representing 12.23% of the total market.

6 Source: http://www.ghanaweb.com/GhanaHomePage/communication/mobile.php

Figure 2: Market share of mobile phone providers in Ghana

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GLO decreased its subscriber base; its current subscriber base of 1,578,446 represents only 6.16 % of the total market share. Expresso though, decreased its subscriber base to 168,572.The 168,572 represents 0.66 % of the total market share.

Ghana now has six Telecommunications companies operating in the telecom sector. Companies like MTN, Vodafone and Tigo who changed ownership over the years still maintain the higher market share, although competition is growing. Companies like Airtel, Espresso and Glo are still small. All three together share less than 20% of the market share.

The accuracy of this information is not verifiable and caution must be taken since the source is an internet site, with information mainly provided by the Ghana News Agency (GNA). It is included here to be indicative of this rapidly expanding market in Ghana.

Figure 3: MTN coverage Koforidua (left) and Kumasi (right) with red circles showing 3G (green) and 2G (blue) networks7

Mobile phone network coverage is still under development in Ghana. There are an estimated 824,297 cell towers throughout Ghana but these are situated primarily in major commercial hubs and do not serve the entire population. The mobile coverage maps are in constant flux as this is a rapidly growing market sector. As shown in Figure 3, Koforidua’s MTN coverage (supposedly Koforidua’s best service provider) is quite low compared with Kumasi’s MTN mobile coverage area indicating that smaller towns are not as well served as major cities. This could present a difficulty in ensuring adequate coverage of at-risk populations when the pilot program is scaled up to cover other areas of the country, particularly in remote rural areas where malaria transmission is high.

The technology platform for this program was created and managed by MEDA in Canada and Ghana has benefitted from the research and development time and money which went into the successful eVoucher design for Tanzania. MEDA’s system in Canada is hosted online and this is integrated with the technology partner in Ghana - SMS Ghana’s two-way Application Programming Interface (API) into their system in Accra. After this integration, MEDA send SMS Ghana a URL address to their application. This online address is used to communicate between the two systems. It takes between one hour and three days to set up this program, i.e. for the local gateway provider to establish the link to MEDA’s URL and test the connections. When interviewed, SMS Ghana stressed that technology is not the problem in Ghana – the problem is network coverage - which can be patchy and inconsistent. However, SMSGH had several times where systems maintenance on their part caused disruptions to the service. The mobile phone networks in Ghana have many “downtimes” which was

7 Source: http://www.sensorly.com/map/2G-3G/GH/Ghana/Koforidua/

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witnessed in Koforidua during the process evaluation and reported by many respondents as a problem in successfully implementing the eCoupon program.

LLIN eCoupon Scheme Process The evaluation team found the description of the overall LLIN e-coupon scheme process included in the evaluation scope of work (see below and also similar brief description in the Ghana eCoupon Implementation Plan document dated 27 June 2013) to reflect what is implemented in the field. The subsequent sections of this findings section describe in more details the experience related by the various stakeholders and findings from the consultants for each steps and aspects of the program.

The process appears to be straightforward for both issuers and redemption outlets. There have been some misgivings about customers having the burden of obtaining an eCoupon in one location and having to redeem it at another separate location. Recruiting issuers and redemption outlets on a ratio of 1:1 is being trialed to ensure that the issue and redemption outlets are located close to one another. E-coupon self-issue is also being considered as a way to overcome this, thus enabling the customer to visit just one redemption site. There was insufficient data available at the time of the process evaluation to recommend which is most effective. Figure 4 below provides an illustration of the eCoupon used in the pilot program.

Figure 4: Sample of eCoupon used in pilot

Box 2: Brief description of the LLIN e-coupon process

The eCoupon is one effective methodology to implement a subsidy intervention. Ghana has piloted paper vouchers in LLIN distribution in the past (2004-2010). An e-coupon is conceptually similar to a paper coupon but it differs in using a digital/electronic platform. Use of the e-platform reduces the required number of management staff, improves efficiencies, and reduces fraud. An e-coupon issuing point (health clinic, workplace, or other participating issuer) gives out a coupon with an electronically generated discount code (written onto a pre-printed coupon) to a target beneficiary. The beneficiary can then redeem their coupon at a participating retailer for a net, paying only the top-up. The retailer submits the coupon code using their mobile phone. Issuing points are set up in the system with an appropriate discount based on the donor funding the subsidy (e.g. a workplace coupon discount may differ from a health clinic discount since the employer directly funds their own workplace coupon). The e-coupon database is able to track which issuers and retailers are issuing and redeeming e-coupons on a continuous basis.

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eCoupon Issuers Issuers (including Post Offices, Mobile Phone Credit Vendors, Clinics, Hospitals and Community Information Posts) are on the whole able to understand the SMS issue process and find it easy to perform. The current number of e-coupons issued over the 11 week period (Sep 23rd – Dec 3rd) is 2,261. All issuers are giving of their time and service voluntarily. Most state that they are doing this as a community service. Training takes between one hour (at issue site, individually) and three hours (at workshop organized for a group of participants). The Project Coordinator found that knowledge retention, enthusiasm and skills were enhanced through the participation in group training, rather than one-to-one, in situ possibly due to positive group dynamics and ability to focus away from place of work.

Figure 5: The issuing process as illustrated on the Job Aid, given to all issuers

The above Job Aid illustrates the process of issue and there were no misunderstandings found during the process evaluation, although nearly all experienced problems with lack of network coverage when issuing. Figure 6 below illustrates the number of coupons issued by issuers in ascending order of number. It reflects clearly that the schools program is the most successful in issuing coupons. The most successful issuer in the private sector environment is the private hospital/clinic. The three issuers with the highest redemption rates were St Joseph’s Hospital, which had a redemption rate of 63%; Bonna Clinic, 77%; and Koforidua Clinic, 88%. This may reflect the nature of the relationship between the issuer and the potential net purchaser. A number of retailers mentioned that they felt customers were more likely to purchase a net if they have been recommended to do so by a trusted person, ideally a health practitioner in a clinic. When interviewed, the Bonna Clinic administrator spoke of how the program also reflected well on his clinic. It was seen to increase the prestige of his clinic to be able to offer clients discount coupons for net purchase. He was the only person to suggest

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this, but it is a useful endorsement for program participation, when recruiting other clinics. He also revealed the problem of delegating the task of coupon issue. Less senior staff do not approach the task with the same dedication and so he himself has had to resume issuing and he has less time to do so. The clinic has a client load of 70-80 clients per day. He admitted the program had not been as successful as he had anticpated and that demand was low, mainly because – in his opinion - there is not a strong net use culture. One of the reasons the Bonna clinic has performed so well is that they have bulk issued 20 coupons to a Church program (approved by NetWorks).

Figure 6: Number of eCoupons issued during pilot by outlet (23 Sep to 3 Dec 2013)

Teachers also hold some authority over their target benecifiaries, i.e. their school children, in the primary setting; whilst in the secondary setting is is policy for all first year students to bring nets to boarding school. From the other outlets there is little to differentiate them, since numbers were so low, ranging from only four to nine coupons issued in an 11 week period. However, if further analysis in undertaken (Figure 7), the data reveals that the outlet types vary again in the successful redemption of those coupons issued.

Figure 7: Average redemption rate in % by issuing outlet; in brackets number of outlets involved (23 Sep to 3 Dec 2013)

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The employer program had not started when this evaluation was underway. However, Information provided by the project after the process evaluation (and thus not included above), state that a 60.3% redemption rate had been achieved by the 19th of January through the employer program with one employer (VREL). It is believed that this figure would have reached closer to 90% had it not been for a delay in the delivery of 150 nets. This delay meant that some of the e-coupons originally issued went out of date; the project identified the voided e-coupons and will reissue once nets arrive. However, schools again appear to be performing well, with 50% average redemption rate amongst both primary and secondary schools. The mobile phone vendors are also performing well in terms of successful redemption of coupons issued: 29 coupons were issued by these four vendors and 14 were redeemed, giving an average redemption rate of 49%.

The one Post Office issued five coupons and only two were redeemed. This outlet was interviewed and it appeared that the post office worker was not a local member of this rural community where the post office is situated and so she did not know the residents of the area well. It appeared that there were not many customers using this post office, although the worker said that 15-20 people use the post office per day. The post office worker believed that many in the community still possess the free nets issued by the government program and that the current price of double nets8 (11 Gh c) was still too costly for many in the community. It is understood that the national Post Office network could be approached by the project to adopt this program and make e-coupons available in all post offices nationwide. The Post Offices are themselves struggling to retain relevancy in changing market conditions and so this may be a program they would adopt in order to diversify their service offering beyond postal services, collection of school fees, letter box collection and Western Union services. Two Community Information Centres took part in the pilot program. 26 coupons were issued, and 10 of these were redeemed. The lowest performing centre was interviewed – the Jumapoman Centre. This centre has only issued four coupons, none of which had been redeemed. (In contrast, the Suyhen centre had issued 20 coupons, eight of which had been redeemed.) The Community Committee Chairperson ran the information centre for the community which numbered approximately 1000 people. The reason given for low uptake was that the local ANC clinic was providing nets for free and people in the community still expected nets to be free of charge. The community posts usually charge for social announcements to be broadcast by megaphone to the community. The charges are 10Gh c for three announcements. Announcements are made daily, in the early mornings and evenings. It appeared that the community service nature of this program was something that the community information posts would be willing to get behind. If the program were to scale-up, it may be something to watch for – that charges may be made for continued activity. Internet café’s/ICT centres do not appear to be performing well. During the evaluation, a new ICT centre was recruited to serve a retailer nearby and act as an additional issue point for a large secondary school and situated opposite the Polytechnic. It was clear that the centre was extremely busy and there did not appear to be a lot of interaction between workers in the centre and the students and clients using the photocopiers and computers. It therefore does not provide much social interaction nor opportunity to discuss coupons and nets. The newly recruited owner of the internet café said that he would only participate as a favour to the retailer who was known to him. The owner was expected to train his workers, since he is not always present in the venue. This could be another potential weakness, since there would be little buy-in to the program from his workers. The

8

Single Bed size = 100cmx 180cm x 150cm; Double Bed size = 160cm x 180cm x 150cm; CONICAL = 1050cm (bottom circumference) x 200 cm (height) x 56cm (roof circumference) Source: Tana Netting (Width x length x height)

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recruitment process took 55 minutes (with a few interruptions to service photocopiers). During this process there was no success in simulating the SMS process, even after three attempts. Issuer respondents were asked if they received an incentive and whether this was required or expected for continued participation in the program. Many found this an embarrassing question to answer. However, it is clear that some incentive would be required at some point, particularly if the demand for eCoupons increases. Some mentioned the receipt of a net as an incentive, others suggested small monetary incentives would be well received.

eCoupon Self-Issue It is understood that the pilot will test self-issue of coupons. This had not been done at the time of the process evaluation. E-Coupon self-issue would entail customers applying for an eCoupon directly on their own mobile phone – after seeing instructions on a poster or hearing a radio advertisement - and taking the eCoupon on their mobile to the participating retail outlet, thus cutting out the middle man – the eCoupon issuer. The acceptability of self-issue was asked during the interviews with stakeholders and there was a mixed response; however, of the 30 general population interviews conducted, the majority (23) indicated that they would not be prepared to apply for eCoupons on their own cell phones. The responses seemed to vary with age of respondent, the younger being more keen to adopt new methods than older respondents. There was a general feeling that this would require a great deal of communication and promotion to encourage consumers to adopt this new activity, particularly since LLIN demand is currently so low. However, the acceptability of self-issue can only be determined after an actual trial of this methodology.

eCoupon Redemption Outlets The below Job Aid illustrates the process of coupon redemption and sale of subsidized net.

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Figure 8: The Process of redemption is illustrated on the Job Aid given to all retail redemption outlets.

Figure 9: Number of eCoupon redemptions per LLIN selling outlet type during the pilot (23 Sep to 3 Dec 2013)

Figure 9 above shows the total redemptions made at each of the four outlet types giving or selling LLIN. There were a total of 633 redemptions made amongst the 27 outlets over the 11 weeks. Of these 633 redemptions, 370 were made by the general public (7 Gh c subsidy); and 263 were made using the primary school coupon (100% subsidy for single net size).

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Figure 10: Mean number of eCoupon redeemed per LLIN selling outlet type during the pilot (23 Sep to 3 Dec 2013)

If the number of the different outlets is taken into account, a slightly different picture emerges (Figure 10). There were three schools, redeeming a total of 148 coupons and so they were the most efficient redemption outlet type. There were eight pharmacies, which redeemed the 282 coupons and so they were an effective redemption venue. They are also more likely to have stocked nets before and have more room to store the bulky products. The five general stores redeemed 86 e-Coupons. However, one store – Doris Adjei – redeemed 32 coupons which was highly unusual for any venue to redeem this high quantity and so this skewed these results. This retailer is situated on the site of St Joseph’s Hospital, the largest health facility in the area, which has a highly active issuer from their Procurement Department. The hospital specializes in orthopedics. The Donkomi program is mentioned at the Outpatients Department every morning. Another reason for high issue is that many come to the hospital from all over Ghana, and indeed West Africa, and so there may be people outside Koforidua accessing these particular coupons and nets. Other general store retailers were very much less active, redeeming between 1 and 9 coupons each from the general public. There were 11 chemical shops, which are generally in less built-up areas, which improves access to the community, and 115 redemptions were made in these outlets. This was the lowest average redemption per outlet. However, this is not surprising, as these are smaller outlets serving a smaller number of potential customers. A problem identified during the process evaluation was the availability of the trained eCoupon staff member. Usually only one person undergoes the training and uses their own personal mobile phone to carry out the redemption. This can be problematic if that individual is unavailable for any reason.

Mapping Using GPS The technology platform, based at MEDA headquarters in Waterloo, Canada, has a built-in function to map the project area using GPS coordinates to locate specific issue points (red) and redemption outlets (blue). This can then be used to analyse coverage effectively and ascertain relative performance of each outlet type based on their proximity to issue points etc. This function was not being used in-country by the project coordinator during the pilot. However, it was recognised that this is a valuable resource for a scale-up. This may be further enhanced if population density can be overlaid on such maps over the time of a scale-up operation as this would provide a valuable monitoring tool.

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Figure 11: Map of retailer (blue) and issuer (red) points from MEDA platform

As the pilot progressed and on-going lessons were learnt, it was clear that distance of issue point to redemption outlets became a hurdle to effective coupon redemption. The further the redemption outlet from the issue point, the lesser the chances of eCoupons being redeemed. During the pilot, therefore, new issue points were recruited on a ratio of 1:1 where possible, as close as possible to each retailer. Initially a 1:2 ratio was thought to be sufficient (issuer : redemption outlets). Again, when thinking of scaling up such a program, it is not clear if it will be cost-effective to recruit one issue point for every one retailer. It is important to ascertain the optimal number dependent on the geographical spread of retailers in each area. It was not possible during this process evaluation, but it is suggested that a further analysis of issue points and retailers is made to ascertain the essential factors necessary in recruitment – is it relationship with customers that is a major driver?; is it central location?; is it proximity to retail outlet? A mapping exercise was attempted using GPS data gathered for the process evaluation. The map in Figure 12 was created, which details the project area more clearly than the MEDA provided mapping tool (Figure 11). It is recommended that the mapping exercise is used to evaluate the effect of location and proximity on the performance of outlets within the program. For example, the three issuers in the SW, near Brodium Bridge do not appear to have close proximity to retailers. There was not sufficient time to analyse the individual outlets in relation to this map, but it is recommended that this could provide a very useful aid to planning location of outlets for the scale-up.

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Figure 12: Map of retailers and issuers based on GPS data

Performance over the duration of the pilot (23 Sept – 3 Dec) To date (3 December 2013) the following has been achieved: Total Coupons Issued: 2261 Total Coupons Redeemed: 633 Redemption Rate: 28% However, this includes miscellaneous data, which can skew the results: i.e.

i) Multiple Concepts Launch activity (1171 issued / 54 redeemed) = 5% redemption rate ii) Primary Schools Program (530 issued / 263 redeemed) = 50% redemption rate

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Therefore if we present the information without launch activity data: Coupons Issued*: 1090 Coupons Redeemed: 316 (general population) and 263 (primary schools) = 579 Redemption rate: 53% *Total 2261 minus 1171 coupons were issued at launch by Multiple Concepts = 1090 If we then remove the Primary School Data, to focus only on the general issuer redemptions: General Population Coupons Issued: 560 General Population Coupons Redeemed**: 316 Redemption Rate: 56% **Total general population redemptions (370) minus promotion redemptions (54) = 316 Despite very low sales figures, this gives a retail redemption rate of 56%, which compares favourably with the TNVS e-coupon program, which has averaged redemption rates of 62% in their pilot year, which trended upward to 72% in December 2012.9 The figures below show the weekly results of the program over the 11 weeks. As stated, the promotional campaign launch issue of e-Coupons, carried out by Multiple Concepts, is believed to have distorted the program results, since 1171 e-Coupons were issued during their 2 week campaign, but only 54 were redeemed, giving the redemption rate of only 5%. This was an inefficient method and so charts have been included to show results with (Figures 13 and 14) and without this contribution (Figures 15 and 16). These Figures show the total issue by week and how that issue was divided into coupon redemption; coupons that remain outstanding (still to be redeemed); and coupons that are void (expired unused).

Figure 13: Weekly redemption rate in % including promotional campaign

9 Lessons In Brief No. 7 Tanzania: Making Targeted Subsidies Fast and Flexible. The TNVS eVoucher, RBM, UAID, NetWorks, 2013

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Figure 14: Outcome of issued eCoupon per week with promotional campaign

Figures 15 and 16 give a more accurate picture of the private sector e-Coupon issue and redemption, without the Promotional campaign launch issue.

Figure 15: Weekly redemption rate in % without promotional campaign

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Figure 16: Outcome of issued eCoupon per week without promotional campaign

The redemption rate grew quite steadily over the first five weeks with a peak in week seven, following the primary school issue, which cause the spike in issues (651) and redemptions (346). Otherwise, it is clear that the program suffered from a decline in activity after week 6. In week 11 there was a significant final push with 50 coupons being issued and 41 of those being redeemed. It is clear that without significant management inputs and continual support, the program could show a serious decline in both issue and redemption. This spike is believed to be a schools’ issue; secondary schools were being recruited during the process evaluation, late into the pilot program.

Customer Feedback It was not possible to find members of the general population who were participating in the pilot via exit interviews at retail outlets. Therefore telephone interviews were conducted with a selection of people who had given their mobile numbers when redeeming their coupons. The majority of respondents already owned a mosquito net, which leads one to assume that such early adopters of this eCoupon program may possess a net culture. Of the 30 interviews, all 30 reported that the net obtained through the eCoupon program was used. Awareness was stimulated by a variety of sources: the public sector mass free net distribution and hang-up communication campaign was mentioned, alongside radio and the launch activity Donkomi van. The main negative aspect expressed by recipients was in having to produce an ID card for eCoupon issue. Price appeared to be acceptable with 23 respondents stating that the level of subsidy was acceptable, making the net more affordable to buy. Seven stated that would rather pay around GHS4.00. The issue of free supply was also mentioned, it is clear that this is still understood as the preferred norm in the project area.

Schools Program The Schools Program ran parallel to the general population pilot. The program was tested with one set of primary school children in Grade 4 (P4). This pilot coincided with the Education Department’s free net distribution program, which is being conducted in the Eastern Region. The latter program distributed nets to P2 and P4 in school year 2012 and in 2013 are distributing nets to P4 and P5. However in Koforidua, the free distribution was held back (until Feb 2014) to allow the pilot to run. Children in P4 are given eCoupons (as pictured below) by their class teacher. This clash of LLIN

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programs is problematic and was one of the reasons for the demise of the previous voucher program trialed in Ghana10. It is essential that this be avoided through strategic planning of the roll-out closely coordinated with any other public sector LLIN initiatives.

Figure 17: Sample of eCoupon issued at schools

This schools coupon (pictured above) entitles the children to a free single-size net (as at value of 7Gh c). A list of participating retail stores is attached to the coupon, for redemption (on an ordinary sheet of photocopied A4 paper). The regional Education Directorate was willing to participate in the pilot and saw the value of utilizing the private sector. The Education Directorate representative interviewed believes that all pupils from P1, 2 and 3 could also participate with coupons taken home to parents; while children in P4, 5 and 6 were old enough to redeem free nets from retailers themselves. He suggested all primary children could participate in a coupon program. He said schools were chosen for the pilot, which had close proximity to a pharmacy and therefore ease of access for redemption. Indeed the pharmacies redeemed 74% i.e. 194 of the total of 263 schools coupons redeemed. He believed that this was a new concept and so would take time to be accepted, but he did state that the free distribution required less effort for parents and so was preferable to a coupon program if sufficient budgets were available. He felt that it was not a good time to introduce the eCoupon program because the free distribution in schools was currently on-going. Indeed, the new batch of children in P2 and P4 would be issued free nets again in March 2014. He also stressed that he had not been kept fully abreast of the results of the pilot and would welcome regular monthly reports of progress. This would maintain motivation of staff and give information to be reported to superiors to ensure program buy-in. Currently, for the pilot, due to the limited number required, the schools coupons were written by hand with eCoupon generated numbers before being given to teachers to issue. This obviously would not be replicable at scale. Therefore an alternative strategy will have to be considered. It cannot be taken for granted that teachers would be willing to give their time to generate eCoupons for their classes. This will need to be trialed to ascertain the most effective method.

10 Introducing vouchers for malaria prevention in Ghana and Tanzania: context and adoption of innovation in health systems; de Savigny, D. et al; Health Policy and Planning 201227: iv34-iv42. (N.B. This article is summarized and included in Annex VIII)

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It is clear that participation in the program is an Education Directorate directive and so this ensures that schools undertake the program. The feedback received from Teachers was favorable to the program. One teacher used the eCoupon as an opportunity to educate the class about malaria and the use of nets (using materials supplied by NetWorks project). She said that she would not have done this, if it were not for the coupon program. Schools did request that teachers be given LLINs as an incentive to participate in the program. Others asked that the program be made available to children in other grades, since it should be of benefit to all. However, the schools program has a very obvious pattern, since there is a volume issue and redemption spike and then no further activity (see Figure 15 and 16). It also remained unclear, how the school eCoupon would in a scale-up be related to the free school distributions, i.e. whether it would replace these or be in addition.

Employer Program At the time of the process evaluation, neither of the two plantations in the pilot had started their coupon issue program. One of the plantations (VREL) had been selected in the basis of an existing relationship with JHU Voices Project over a number of years. Initial negotiations for the pilot program had begun with Volta River Estates Ltd (VREL) in late August. They were recruited in early October but the internal approvals within the company took much more time than had been anticipated. So, issue only began on the planation on Monday 9th December. The other plantation, Golden Exotic (Dole), had similar delays with internal processes and approvals and will be starting their program a week later, on Monday 16th December. It is understood that VREL has a sister company which is also interested in joining the pilot program. VREL has a workforce of 450 employees. The arrangement has been made that each employee is entitled to two coupons (two nets). An initial stock of 300 nets has been placed in five retail outlets in the villages in which employees are known to reside. The amount of nets has been allocated on the basis of resident employee numbers in the vicinity of the retail outlet. The researcher went into VREL during their first week of implementation and found a muted response to the eCoupon program. There had been very little publicity (posters and staff memo) and so there was not a lot of enthusiasm for the program. It appears that VREL has supplied nets to its employees in the past, so this is not considered a major perk for employees and the eCoupon process was not fully understood. It is therefore too early to assess the employer program activity within this pilot. However, the process for recruitment and selection of employer sites to work with is an area that would need a significant amount of preparation and work in identifying potential partners and advocacy and support in winning companies over to the concept and getting their agreement to co-pay. Employers are investing their own funds into the co-pay arrangement. The current pilot design requires a donor subsidy of 40%; an employer subsidy of 40%; and an employee co-pay contribution of 20% of the price of the net. An issue to consider when scaling up is the need for dedicated mobile phones for issuers. VREL asked the project to buy phones for their issuers, as they felt they could not expect employees to use their own phones (even though SMS messages could be sent free). For the two pilot mobile phones were loaned to VREL staff by the project, VREL contributed three phones. This is an issue when considering cost savings to be made at scale. An advantage to the employer program is that companies often keep health information on their employees. This would therefore offer the opportunity to accurately track the impact of the eCoupon

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program on workforce malaria incidence. (N.B. These records were not made available to the evaluation researcher. It is recommend that this data is collated when the program has been running for some time and/or during program expansion, as this could show significant results for employee programs which could be used to demonstrate malaria reduction and potential cost savings to other potential employers to motivate their participation in the program). Results obtained after the Process Evaluation Visit as reported by the project:

The evaluation team received, at the time of finalizing this report, employer e-coupon issuance and redemption data from the project up to 19 January 2013; these are presented below (Tables 3 and 4). It includes only the VREL plantation, as Golden Exotics redemptions had not started yet due to ‘net supply/payment issues’ (unspecified).

As already stated, there are higher issuances than redemptions on VREL, due in large part to a payment issue problem on 150 nets, which delayed the arrival of the next batch of nets. This delay meant that some of the e-coupons originally issued expired; the project identified those voided e-coupons and will reissue once nets arrive.

Table 3: VREL eCoupons issue and redemption results 18 November 2013 to 19 January 2014

eCoupon status Number Proportion Issued, Not-Yet-Redeemed 32 3,5% Redeemed 555 60,3% Void 333 36,2% Total Issued 920 100%

Table 4: Week by week number of eCoupons issued and redeemed at VREL - 18 November 2013 to 19

January 2014

eCoupon status

Total Nov 18- Nov 25- Dec 2 - Dec 9 - Dec 16 - Dec 23 - Dec 30 - Jan 6 - Jan 13 Nov 24 Dec 1 Dec 8 Dec 15 Dec 22 Dec 29 Jan 5 Jan 12 Jan 19

Issued 920 5 0 0 543 36 131 45 150 10 Redeemed 555 0 0 0 273 3 195 57 27 0

Distribution and Supply Chain Pricing After discussions with both the Director and Dawa Net Salesman of Agrimat, no cost information was obtained regarding the landed net cost and the mark-ups attained along the supply chain. Both were particularly keen to remain non-transparent in this. It is important that full transparency is requested

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of distributors who join the program and that this is part of their agreement with NetWorks. From the outlet questionnaires, it was possible to ascertain the current cost and co-payment breakdown as per Table 5 below:

Table 5: Net Supply Chain Pricing

Net size Full price (Ghc)

Cost components (Ghc) Co-payments (Ghc)

Retailer margin

Distributor margin

eCoupon value (reimbursed by

Networks to retailer) Consumer co-

payment Single 14 3 4 7 7 Conical 17 3.50 6.50 7 10 Double 18 4 7 7 18

However, the two other net manufacturer representatives Vestergard Frandsen (VF) and Bayer were also interviewed. VF (represented by Health Alliance Network Ghana) are currently supplying the NMCP continuous distribution free nets. They were the only prepared to give cost information as follows: Landed Cost: 13 Gh c Health Alliance to Sub Distributor: 15.60 Gh c (margin 2.60) Sub Distributors to Outlets: 17 to 20 Gh c (margin 1.40 – 4.40) Bayer had its own Regional Representative for West and Central Africa and they use Agrimat as their distributor. They are still not ready to supply their new Life Net in Ghana and stated that they were focused on institutional sales at this time. Agrimat informed the consultants that they had taken an initial order, but it was recently recalled with product quality issues stated as the reason. The Bayer Regional Manager stated that Bayer were not ready to be involved in a project of this nature. The decision to supply nets in Ghana would be taken in late second quarter – to third quarter of 2014. N. B. Of the 27 redemption outlets – only seven put up their own cash up-front. The rest relied on 100% credit from Agrimat. This is unlikely to be replicated at scale and is a serious short-coming of the pilot and any commercial program. It is not representative of how the private sector business would operate. Agrimat stated that they had to bear all the risk by selling on credit. It is understood that credit was offered to ensure participation of as many retailers, as quickly as possible in the program, to enable the mechanism (and nets) to be in pace to test the eCoupon concept. It is obvious that the private sector LLIN distributors are still recovering from being abandoned by mass campaign policies. They are also somewhat distrustful of public sector initiatives, having been so badly burnt in the past. It is therefore worth considering other possible distribution avenues, for example mattress suppliers. During the evaluation, a very preliminary meeting with Ashfoam, a leading supplier of foam mattresses gave an indication that there may well be other distribution methods utilizing private sector supply chains, which should be considered.

Operating Environment / Partnerships This is a weakness of the pilot, which would need to be addressed in any scale-up. The Eastern region has one of the highest percentages of net ownership following the mass free distribution campaigns of December 2010 and April 2011. At the time of the pilot, the Eastern region was also undergoing the Primary School free distribution program to children in P4 and P5. Ownership of LLINs was at 78%

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Box 3: Pictures of launch activity

(MICS, 2011) with an average of 1.5 nets per household in this region. Therefore this was not a particularly favorable environment within which to try to stimulate a commercial demand for nets, since net ownership is already quite high here. This is another explanation for the low net redemption rates.

LLIN Demand Creation / Pilot Promotion There is low demand due to possible saturation of free product in the pilot area and a low “net-use culture” in Ghana generally. This was compounded by the demand creation exercise in the pilot area being limited in weight and penetration. Multiple Concepts (a promotions company) were hired to perform a launch activation program in the town of Koforidua over two weeks (2-15 October 2013). Multiple Concepts’ Account Manager explained that usually they like to have a presence over four weeks for a launch and follow up with further activation activities, after a period of three months. 10 promoters went around in a branded vehicle, wearing branded T-shirts, using specially designed Donkomi bells to draw attention, talking to people in the streets and issuing coupons (95% of which were not redeemed). The pictures in Box 3 were provided by Multiple Concepts showing the launch activity.

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Box 4: Pictures of point of sales materials used during the pilot

Box 5: Pictures of radio program

However, there was a good point of sale presence for the campaign at both issuer and redemption outlets (see Box 4). They included a PVC banner and detailed the retail prices of the three sizes of nets and an A-Board which was for street display. Many were observed during the pilot evaluation, and the yellow and blue materials stood out very clearly and were very easily identifiable. Demand Creation: Radio was used as the primary vehicle for on-going demand creation. Local radio stations were selected for both 60 second advertising and LPMs (Live Presenter Mentions). These were used because Multiple Concepts believed that this process was a complex message to get across to people. Presenters were therefore given information to further explain the process and give their endorsement to the activity. From the nationwide Multiple Indicator Cluster Survey data (2011), it is clear that radio listenership is quite high11. However, from interviewing people in Koforidua, they say that they listen more to national or Accra based radio stations than their local stations. Three local stations were used: Eastern FM, Sunrise FM and EMAK FM. Two of the radio airtime schedules are provided in the Annex VI. It is clear that this campaign was running at a very light weight. This coupled with the finding that many residents of Koforidua appear to listen to Accra-based radio stations, such as Joy FM or Peace FM, would imply that the radio campaign was not an effective campaign in creating awareness of the Donkomi program.

11 MICS Survey 2011 Exec Summary: “For both sexes, radio is the most predominant media for 69 percent of women and 80 percent of men.”

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BCC: It is clear that more resources need to be put into BCC for net use and the benefits of LLINs, which appear little understood. Some respondents asked about retreatment of their net with insecticide tablets and few appeared to understand the concept of ‘long-lasting’. Further – there will need to be a consistent communication campaign coming from NMCP and NGO partners which educates the population of the value of LLINS, the product attributes and the fact that the free product is a one-off and how people can purchase additional or replacement nets in the shops. These do not appear to be key messages in the current national communication campaign for malaria prevention, led by UNICEF.

Acceptability / Continued Support This is a difficult issue to ascertain. The current program appears to be relying on the goodwill of a number of key partners: firstly, the distributor, Agrimat. Currently, the distributor believes that this program is making a loss as there is very little product demand resulting in very low net sales. The distributor has intimated that it is not commercially viable for him to continue in this program. The only reason that he does so is out of a belief that malaria prevention is good for his country. He does not see this as a commercially viable product at this time. Further reliance on good will is taking place at the issuer level. These people gain no benefit in issuing coupons. They do so with no monetary reward or incentive. For most, it is done through a sense of giving-back to their community. However, without constant support and monitoring, this could become a major weakness of the program. During the pilot, very little time is spent ‘training’ issuers - there was just one 3 hour workshop held. Other than that, random visits are paid by the Project Coordinator. These issuers could be product champions, although most are not in positions of trust that would give weight to their claims, i.e. post office workers, mobile phone credit vendor, information post holders. It is only the private hospitals that appear to have the authority, but staff that are issuing are in clerk and administrative roles and so again, without doctors or nurse advocacy they are unlikely to be persuasive. Lastly, but importantly, the retailers – many are seeing this as a very slow moving product. As most are sold on credit there is not real loss to retailers, but they do not have much faith in demand generation for this product. Those early retailers who did invest some capital are more vocal about the fact that this product does not move. Knowledge about product attributes appeared to be quite low here too.

Cost of the pilot program Analysis of pilot program costs can be misleading since this was a very short pilot in a limited geographic area, testing a variety of different methodologies. They are being supplied because they were requested in the original scope of work. They should by no mean be interpreted as a reflection of what might be obtained at the end of the pilot period or could be obtained in a similar program implemented at scale.

1. The cost of the pilot phase per net delivered:

• The approximate cost per net delivered was estimated at $200, based on sales of 633 nets

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• Only 3% of the original sales target was achieved • The original cost per net delivered target was $4.75 based on target sales of 20,000 (this did

not include the promotional budget)

2. Potential for lowering costs in a scale up

• Cost per net sold, when apportioned over a larger project area, achieving a greater volume of LLIN sales.

• Software design and development costs • Technical Support costs

3. Distinguish sunk costs for start-up vs ongoing program costs

• Start-up costs were approximately 24% of total project costs

• Considerable savings will be possible during scale up from having already established technical program components during the start-up, such as:

o Software Design and Development o SMS Short-code set up o Technical Consultancy fees and travel costs

• On-going program costs will increase with a scale-up but can be amortized across additional nets sold in a larger geographical area

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SUMMARY AND CONCLUSIONS

Program Efficiency It is worth stating that this is a very short six month pilot program and so it is not expected to show efficiencies from the outset, since projects will incur greater start-up costs which would be expected to balance out over the life of a full program implementation. The most obvious statement to make is that the pilot project fell far short of the original net sales target envisioned for this 6 month pilot. The project had estimated a target of 20,000 nets sold over six months. The actual number of nets sold (633) was only 7% of the target if one considers that a target of 8,800 would correspond to the 11 weeks the pilot had run. It is unlikely that there were major program flaws or inefficiencies which led to this vast shortfall, but rather a very unrealistic initial market prediction, perhaps based on an over-optimistic understanding of the context for net sales in Ghana. The result is a misleading high cost per net sold figure of nearly $200 per net sold. This makes the program appear inefficient and unsustainable. However, this is a very small pilot program and thus this cost does not reflect what could be obtained at scale as large cost savings can be made in scaling up a program of this nature. It is clear from these early cost estimations that the only way that this program can be considered viable is to vastly increase net sales. This will be discussed further in Program Effectiveness Currently, the start-up costs of the Ghana eCoupon pilot are estimated to be 24% of total cost. The cost of the Tanzania eVoucher platform developed by MEDA in partnership with its software design firm PeaceWorks, cost $62,11912 in initial external technical support. This initial R&D work has considerable cost saving benefits in Ghana, which does not have to replicate such complicated design costs. These are all sunk costs and so significant savings will be made in scaling up the program, but efficiencies in operating costs will still need to be made. One major concern for the implementing agency, which cannot be stressed highly enough, is in keeping management costs for this program as low as possible. Currently the pilot management agency costs are running high at approximately at 39% of the total budget. Following interviews with the NMCP (as stated by both the NMCP Manager and the LLIN Steering Group Chairperson), it is clear that high management agency costs proved to be one of the major reasons for the cancellation of the previous net Voucher program conducted in Ghana in 2003. The NMCP will require a transparent process and assurances that a scaled-up program will keep management agency costs low. The transparent nature of the e-Coupon process will be an advantage and if the program management costs can be kept to a minimum, it will encourage the government stakeholders to fully embrace the program. Some operating costs will still require higher investment: The promotional spend during the pilot (approximately $31,730, 25% of total spend) proved to be ineffective. The Activation Campaign was implemented for only two weeks and may have been rushed (the promotions agency stated that they normally carry out four week activation programs). It also proved highly wasteful in terms of coupon issue with only a 5% redemption rate attained. A redesign is needed for a more efficient and effective

12 Lessons in Brief No. 7 Tanzania: Making Targeted Subsidies Fast and Flexible. The TNVS eVoucher, RBM, UAID, NetWorks, 2013

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Activation campaign and continued demand creation efforts. The pilot radio campaign focused on local media stations: Eastern FM, Goodlife FM, Sunrise FM and EMAK FM. These local stations, although probably cheaper than stations with a larger reach, were found to be lacking in listenership for the area. Interviewees reported listening to Accra stations, such as Joy FM, which has a reach in Koforidua (but would not have been cost effective for a Koforidua-only reach). Further Behavior Change Campaigns will need a significantly high spend behind them to complement the promotional advertising, over a considerable period to try to stimulate a very low demand for net purchase. As stated, the concept of net purchase is still not understood in Ghana, nor is it national policy and so the public still expects to receive free products. For an eCoupon campaign to be successful there needs to be a great deal more work in recreating net purchase as a social norm in Ghana. This was done successfully in Tanzania because subsidized provision was tied into the existing voucher program and so all TNVS nets are obtained through the private sector. Currently, Ghana does not plan to involve the private sector to a large degree in net provision (as has been implemented in the TNVS in Tanzania) as part of the continuous distribution strategy, NMCP stated that a mixed model of net supply is preferable in Ghana, “Ghanaians like variety” (NMCP Manager). This implies that the overall concept and role of the commercial sector needs further discussion and acceptance before a nation-wide eCoupon program can be successful. Another major promotional cost is the discount provided on the net purchase ($3 per net). This discount was mostly accepted by respondents, unless they simply stated that nets should be free. Obviously, as sales increase the subsidy line-item will increase. According to MEDA, the voucher program in Tanzania was designed to be established over 10 years, but there is a belief that five years in Ghana should be sufficient to establish the eCoupon program. This is a questionable assumption and carries significant risks, which could affect program efficiency and effectiveness, not least the problem of attaining stakeholder buy-in from the NCMP and key national and regional partners. The NMCP Director reinforced that due process would be necessary before any national program is adopted in Ghana and this will have significant time delays on taking this eCoupon program to scale i.e. the pilot once accepted, would first have to be implemented in one district, then one region; then different epidemiological zones, to confirm any regional variation; results would have to be demonstrated before the program could adopted as part of the national strategy. DFID, who have expressed interest in funding such program at scale, have stated that they are unlikely to continue funding Ghana after five years, as it has achieved Middle Income Country Status. The Project Coordinators would be best placed within the pilot geographical area that they manage. During the pilot, he was required to travel between Accra and Koforidua, which proved logistically difficult to manage. Travel and time cost efficiencies will be made having local coordinators, with local knowledge, based in their areas of operation. With program expansion, it is recommended that a project coordinator is recruited for set-up of each area and that an additional position is created for central coordination and stakeholders management in Accra, thus management costs are likely to be higher but should prove more efficient and effective. The platform provider, SMS Ghana management costs are reasonable, but there was a very low SMS use achieved during the pilot. They stated that the program was currently vastly underutilizing the capacity of the system’s platform. The pilot was only able to generate 2261 incoming SMS messages and 663 outgoing messages, over approximately 90 days. SMS Ghana stated that if the program were able to generate 50,000 bulk outgoing SMS messages, a renegotiation would be possible on the current rate of less than Ghc0.1 per outgoing message. It is therefore unlikely that cost savings can be made in this area, rather as net sales increase, the cost of this function will also increase. eCoupon self-issue was considered briefly, through inclusion as a question asked of respondents in the pilot area. It is understood that this will be piloted in 2014 as a potential method to increase the

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uptake of coupons and subsequent net sales. From the responses obtained in the questionnaires, this method should not be considered a way of increasing sales dramatically. It is not necessarily the SMS methodology which is the preventing net sales. Nor is it likely that the coupon methodology will be vastly improved by self-issue. This method would also require a significant investment in promotion for it to stand any chance of success. Again behavior change communications would be needed to complement any promotional effort, since the problem is that net demand is still rather low, partly due to lack of motivation and partly due to a high level of LLIN ownership. Currently, a major cost saving for the pilot is in the recruitment of issuers. During the pilot, issuers gave their time and services free of charge to the project. It became clear that this method would not be sustainable over a long period with a larger scaled program. Some issuers stated that they would appreciate some form of compensation to continue participation in the program. At the very least, regular meetings/workshops with issuers are required to show appreciation for their contributions and keep them motivated to continue with the program. The lack of any real incentive for this key partner cohort makes it a particularly risky partner to rely on. Essentially there is nothing in it for the issuers to participate in this program other than a generosity of spirit and desire to assist the community. Indeed, if the coupon issue were to increase substantially, this could mean a greater burden on the time of issuers which could lead to greater resentment, if there is no obvious reward. This reliance on issuers is not mirrored in the TNVS program which works with health personnel issuers enlisted from the public sector. They are mandated to participate from their employer. This therefore is a potential weakness in the current Ghana program design. The pilot program originally envisioned that there would be the set-up of one issue point serving 2 retail outlets. As the pilot progressed, it was found that access was hampered by this approach and that more issue points were needed to serve specific outlets. A ratio of one issue point to one retail outlet was then adopted from late October onwards. This is costly in terms of program time and effort to recruit additional issuers. Strategic recruitment will need to be considered for the follow-on.

Program Effectiveness A major impediment to this program’s effectiveness lies in the Ghanaian context. As stated in a recent journal article detailing the voucher programs of Ghana and Tanzania13, despite seeming similarities between the two countries, they have had very different success rates, largely due to the “specific contextual factors.” The article states that: “In Ghana national-scale implementation of vouchers never progressed beyond consideration on the agenda and piloting towards formulation of policy; and the approach was replaced by mass distribution campaigns with less dependency on or integration with the health system.” According to the NMCP, it appears that despite the pilot program’s introduction, Ghana is very much in the same position today. A major flaw in the current eCoupon program design has been to omit the NMCP and Steering Group members from inclusion in program design, monitoring and implementation. When considering the program scale-up it will be vital to ensure that the weaknesses14 of the last voucher program implemented in Ghana in 2003 are fully addressed as not all have been tackled in this pilot design. CONTEXT FACTORS: PRIVATE SECTOR

13 Introducing vouchers for malaria prevention in Ghana and Tanzania: context and adoption of innovation in health systems; de Savigny, D. et al; Health Policy and Planning 2012 27: iv34-iv42 14 See summary of the above article in Annex VIII

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The private sector net distributors in Ghana were decimated after the move to mass distribution campaigns. It remains unclear to which extent this is due to the shift from untreated or bundled nets to LLIN, or to the mass distributions crowding out the commercial players. Prior to 2004 there were 14 distributors of nets in Ghana, now there is only one active, Agrimat. Vestergaard Frandsen were active, but pulled out of commercial retail sales in favor of institutional sales. Their previous Ghanaian agent is now starting up commercial distribution again as the ‘Health Alliance Network’. Agrimat has been trading in nets for the last 15 years. According to their Managing Director, they are not making any money from nets, but maintain a side-line in nets within his agricultural supply trade, out of public concern and community service. This is only a bulk trade; no retail network had been established before this pilot. He stated that there is no money in nets, as currently LLINs are not a viable retail commodity. Rather in Ghana right now, there is a better return for his investment in government bonds (18%). He stressed most strongly that he does not see this eCoupon program as assisting him to develop the retail market for LLINs. He believes that the program design is wrong and so is not running well, i.e. he had imported 15,000 LLINs for the pilot and has not even sold 1000 nets. He said that he had not been involved in program design and his opinions were not sought, therefore he could not change the program inefficiencies. He called for more flexibility and involvement in the program design if there is a scale-up. As stated, VF pulled out of Ghana and has been focusing on institutional sales for the mass campaigns. An independent agent has just established herself as “Health Alliance Network Ghana”, to distribute VF LLINs, in December 2013. She is willing to participate in an eCoupon scale up, but accepts that she will have to re-establish an LLIN supply chain, which will be limited to major urban centres. She admitted that she could not compete with Agrimat’s agricultural supply chain reach to more rural areas. Bayer has regional representation, but is not yet supplying its new product “Life Net” to Ghana and has no plans to participate in an eCoupon program scale up. MEDA Senior Managers have been in discussions with the international manufacturers who they state are interested in supporting a project of this nature. Foam Mattress Suppliers have been approached to participate in this program. They have a related product – bedding mattresses and an existing supply chain network of local depots. One supplier was met during the evaluation, Ashfoam. They have 880 depots registered nationwide. Unfortunately, in this initial discussion which included the Project Coordinator, Ashfoam were talking about possible participation with a national program as a Corporate Social Responsibility (CSR) activity, rather than seeing this having any commercial interest. They simply said they would buy the LLINs and give them away free with their mattresses. However, this was an early discussion and there is potential here to develop an interesting partnership and so this avenue should be explored further. Employer Programs have also been piloted, and so far have achieved 60% redemption rates. Private sector employers could be a very effective partner in supplying LLINs to their workforce. There is also the added bonus of being able to accurately track the impact of the eCoupon program on the workforce malaria incidence rates. Social marketing was not carried out for an extended period in Ghana. It only ran from 1998-2002 and so it could not be said to perform a priming of the private sector retail market which happened to much stronger effect in Tanzania. This coupled with the formation of the A to Z factory supplying LLINs in-country in Tanzania helped to foster the strengthening of the private sector as a national policy initiative in Tanzania and the subsequent single-minded approach to net supply through the private sector.

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HEALTH SYSTEM

The new 2014-18 Malaria Strategy was in formulation whilst the pilot process evaluation was on going. The first draft is due in January 2014. From questioning the NMCP, the private sector although mentioned in the new strategy does not appear to feature as a primary system for net distribution. This lack of a clear a single-minded distribution strategy was highlighted as a major weakness of the previous Voucher system in Ghana15. Previously, this resulted in conflicting program initiatives, and indeed this pilot intervention clashed with an on-going free distribution strategy in primary schools in the Eastern Region. LLINs were being supplied free of charge to primary school children in P2 and P4, therefore the 3 primary schools in the pilot had to have the public sector campaign put on hold to enable a trial of the eCoupon in the three schools selected in Koforidua. Uptake of the coupons and redemption rates were high. The eCoupon still allowed free acquisition of an LLIN in a retail outlet.

An area which will have to be monitored and kept in mind is the Ghanaian love of “variety” as mentioned previously by the NMCP. Historically in Ghana there have been frequent changes in strategic direction which can cause problems for partners in implementation, e.g. limiting voucher interventions to one area and then mid-term adding Accra, resulting in a flood of stock out of the original intervention area to accommodate a larger demand in Accra16. It is clear that a Steering Committee exists which includes the private sector as stakeholder members. However, it is also clear that the private sector partners, although invited, are not active members of the Steering Committee and so this partnership is not functional. There is still a certain amount of bad feeling, caused by the original private sector initiatives being abandoned when mass campaigns were adopted. These relationships will have to be built up again and trust will have to be restored. Indeed the eCoupon program coordinators and NetWorks Project had not attended the last Steering Group meeting which had been held in December, despite in invitation from the NMCP. The LLIN Steering Group Chairperson complained that NetWorks project staff failed to attend and missed an ideal opportunity to introduce the eCoupon program to Stakeholders at a crucial early stage. This is a criticism of program management since it was clear during the process evaluation that there had been insufficient advocacy for the eCoupon program amongst key stakeholders in Accra.

OPERATIONAL FACTORS:

Having witnessed the very low demand for LLINs in the retail sector and the on-going free supply of LLINS through government health and education programs, one has to question why this e-coupon pilot is being conducted now. The roll-out was planned to follow-on closely from the end of the six month pilot period i.e. January 2014 and yet, the Ghanaian context does not appear conducive to retail net supply at this time. The timing of this program is crucial to benefit from the last five years of DFID health intervention funding, but it appears that operationally, this program is being rushed through without consideration for due process within the malaria community and NMCP in Ghana. The maintenance of a free net culture promoted by current government supply strategies and the weakness of the current private sector net distributors in Ghana compound this timing problem.

Currently, there does not appear to be a cohesive vision for LLIN supply through the private sector in Ghana and the lack of advocacy for the pilot program has not helped to try to address this. Further it appeared that the NMCP were not fully aware of the contribution of USAID to the pilot and the potential for the scale-up from DFID funding. This has echoes of the problems addressed in the 15 Introducing vouchers for malaria prevention in Ghana and Tanzania: context and adoption of innovation in health systems; de Savigny, D. et al; Health Policy and Planning 2012 27: iv34-iv42 16 As above

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aforementioned article, where the weakness of the previous Voucher campaign was seen to be due in part to external agency introduction of the Voucher program, rather than the fostering of local ownership, adoption and embedded strategic implementation. Consistent BCC messages about the importance of LLIN use are crucial to the success of a scaled-up eCoupon program in Ghana. Currently, UNICEF is the lead partner in the execution of the national BCC strategy. From brief investigation it is not clear how UNICEF will integrate the messaging about net purchase within their BCC campaign. This is a potential weakness for the geographically scaled up eCoupon program, as promotion efforts will almost be competing with national campaigns if the message development is not comprehensive and does not incorporate the promotion of net purchase as the new social norm. It was observed that when asked, many respondents could not fully articulate the benefits of an LLIN. The long-lasting attributes of the LLIN do not appear to be fully understood. It may be that the product attributes have been somewhat devalued by nets being made available free of charge. These product attributes are important when considering reasons to purchase a net. Another potential weakness that the scale-up will have to address is the supply of nets to the retail trade on credit. Agrimat complained about this design issue of the eCoupon pilot. Retailers do not appear to complain too much about the slow moving product that the LLIN is currently, because most of them have not had to invest any of their own money into product stock. All the risk is being borne by Agrimat and NetWorks. Some of the seven early retailers who did purchase initial stock from Agrimat were much more vocal about the lack of demand and how this is a problem to their business. Clearly, the supply of 100% credit to retailers is not a sustainable business model17. However, there will need to be a very careful consideration of the impact on retailer’s ability to purchase stock without a credit facility, since lack of sufficient stock supply will also severely hamper successful program expansion. On the positive side however, the eCoupon pilot is able to take advantage of a burgeoning new industry within Ghana – in the e-technology platforms available through mobile phones. The pilot has shown that the eCoupon works. Issue and redemption is possible. The only major hurdle to the success of this methodology is poor network coverage which may be a factor in some parts of the country, particularly rural areas. Through the interviews, it was clear that there were few other problems for people actually using the mobile system for issue and redemption. Over time, as the program expands and promotion and BCC efforts increase, this can only enhance the acceptability of eCoupons. eCoupons give the opportunity for a fully responsive and transparent system. The also enable different subsidy levels to be targeted to different communities.

Conclusion The Process Evaluation determined that the three aims stipulated for the pilot at inception had varying degrees of success: • The pilot had demonstrated the successful creation of an e-coupon platform with capabilities of

efficiently managing subsidies from multiple donors, to a variety of target populations, with differing levels of subsidies for specific targeted populations.

17 Asian Journal of Business and Management Sciences ISSN: 2047-2528 Vol. 1 No. 4 [29-47] WORKING CAPITAL MANAGEMENT PRACTICES OF SMALL SCALE ENTERPRISES IN THE CENTRAL REGION OF GHANA. Article states that “38% SMEs receive credit from suppliers”. Average credit period 2 weeks to one month. Late payment and bad debt are the two main problems in dealing with credit customers.

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• The pilot had been unable to satisfactorily create demand for subsidized LLINs in Koforidua but there has been a good uptake of the program in the one workplace plantation reported upon.

• The pilot had not been able to fully demonstrate a cost effective public private partnership to reach targeted consumers with different levels of subsidies. The one primary private sector distributor partner had shown some unwillingness to continue with the program unless changes were taken in program design. Private sector issuers and redemption outlets also reported doubt as to the viability of LLIN purchase in the current Ghanaian context of LLIN supply.

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RECOMMENDATIONS The report has highlighted the major issues that have arisen from a process evaluation of the eCoupon pilot. A summary of the key recommendations follows: Stakeholders buy-in and contextual considerations for the scale-up design 1. Clearly articulate and formulate with NMCP how a scale-up will be implemented following this

very limited pilot in Koforidua, to include all due process as requested by NMCP. This must include a process of discussion and dialogue with all other stakeholders and particularly the commercial sector participants.

2. Include all private sector distributor partners in design of the program scale-up and price setting to ensure that they are fully on-board and willing to participate in program implementation. They are an essential partner. Include a consideration of alternative distribution partners e.g. mattress suppliers. Include a strategy for how to deal with an initial requirement of credit facilities for retailers. Create an exit strategy for this credit line, at an agreed level of product sales. Stipulate a need for full transparency of supply chain costs and sales data in any Memorandums of Understanding to be drawn up with each distributor.

3. Ensure that any schools program is fully integrated within the current national campaigns for net supply through schools and clarify the role of an eCoupon school program vis-à-vis the free school distributions (additional or replacement).

4. Consider how to secure Community Leaders and Opinion Leaders buy-in for this program

Program management 5. Formulate a Log Frame for the follow-on program, which clearly articulates all risk factors and

strategies to overcome these potential risks, since there are many which could de-rail the scale up program.

6. Consider how the management process can be streamlined to maintain low management agency costs. This will be a major issue for the NMCP and LLIN Steering Committee in accepting and maintaining an eCoupon program in Ghana.

7. Consider the creation of a specific specialist post to recruit and manage businesses for a comprehensive Employer Program. For businesses to be attracted to this program, a sound business case will need to be made to show the benefits of such a program to a company’s workforce and bottom line. Considering the nature of big business, this should be a specialist function and should not be left to a local coordinator, although the local coordination would assist in identification of local businesses.

8. Consider the creation of a centrally based position in addition to local project coordinators position to ensure overall coordination and stakeholders’ management.

9. Retain the services of the current Project Coordinator, for the follow-on design and implementation in some capacity. It is understood that he is a temporary consultant hire for 6 months and has other work lined up after January 2014. His experience and learning will provide invaluable inputs to program expansion, which should be passed on to new local program staff.

10. Ensure that all cost data is maintained by a single agency. It will be essential to have all operating costs to hand when monitoring the scale-up. During the process evaluation MEDA costs and JHU costs appeared to be kept quite separately.

Advocacy and promotion 11. Create an advocacy strategy for promotion of the eCoupon program amongst key stakeholders

both in the public sector and private sector. Ensure that there is a person assigned to execute

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this advocacy strategy. Ensure that the advocacy function is also done at local level with regional health and education officials and ensure that regular reporting of program results is given to foster local ownership of the program.

12. When formulating a larger promotional campaign, work with UNICEF to try to coordinate promotion strategies with national BCC efforts and advocate for inclusion of the promotion of the new social norm of net purchase. Consider the inclusion of high impact, high viability media as well as strong radio presence. Be aware that the media selection may again be hampered by uneven roll-out during scale-up.

Maximise efficiency at each stage of the eCoupon process 13. Ascertain whether the pilot testing of eCoupon self-issue had any impact on increasing issue

and LLIN sales volume. The initial December target sales figures showed an expected increase in sales to 9,700 nets. Determine whether eCoupon self-issue is viable, especially considering the reported consumer acceptability of the use self-issue was very low.

14. Utilise GPS coordinates to map the outlets participating in the eCoupon scale-up. This provides a useful visual aid to assessing outlets with regards to location and proximity’s effect on performance. Use the map generated in this evaluation to assess the pilot outlets.

15. Study the distribution of issue and redemption outlets to try to streamline the number of each required. Considerable efficiency savings could be attained by a more strategic approach to recruitment of partners.

16. Consider the collection of a mobile telephone number for each coupon issued and net redeemed. This could provide a valuable database of potential and actual net owners. The technology partner (SMS Ghana) has the facility whereby bulk messages could be sent to these customers to encourage malaria awareness, correct net use and even prompt treatment of malaria symptoms. Relationship marketing could be developed when sufficient numbers were attained. If this is acceptable it may be a more useful form of ID rather than the Voter registration or Health Insurance card.

17. Include a full program of regular support to issuers and retailers recruited for the program. Ensure that they can effectively promote a net use culture and explain the benefits of an LLIN to potential customers. They are useful and effective advocates for the program if fully informed and motivated.

18. Provide refresher training to issuer and retailer, schools and employer participants in the program every 2 months.

Final evaluation of this pilot scheme 19. Undertake a full evaluation and costing analysis at the end of the pilot to determine an

accurate cost per net analysis and a full account of the total sales volume achieved.

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ANNEXES Annex I Scope of Work Annex II Work Plan Annex III Data Collection Tools Annex IV Sources of Information Annex V Table for eCoupon Issue and Redemption Annex VI Radio Scripts and sample of Airtime Schedules Annex VII Employer Program Materials Annex VIII Summary of Voucher Comparison Article

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Annex I: Scope of Work Background NetWorks is currently implementing a pilot project in Ghana that uses an e-coupon system to offer discounts to specific consumer groups on the purchase of long lasting insecticidal nets (LLIN). The system adapts the mobile-phone-based platform developed by MEDA for the Tanzania National Voucher Scheme to offer multiple donor sources of subsidy, variable amounts of subsidy offered to specific segments of the consumer population, and product variety available to the consumer. The NetWorks project is a five-year, USAID-funded global project to improve and establish sustainable access to and use of Long Lasting Insecticidal Nets (LLINs). The Project is led by Johns Hopkins University Center for Communication Programs (JHU•CCP) and in partnership with Mennonite Economic Development Associates (MEDA) and Malaria Consortium (MC), it seeks to pilot an e-coupon scheme through the private sector in a location in Ghana. By the end of 2012, Ghana had delivered over 12 million LLINs to households through its universal coverage campaign. Ghana went on to adopt a continuous distribution approach after the mass campaigns to sustain high levels of LLIN coverage. The four main channels for continuous distribution are through ANC, EPI clinics, two targeted classes in primary school annually, and private sector sales at full and subsidized prices. Distribution through ANC, EPI and schools has begun and is being scaled up. However sales through the private sector are lagging behind as there is yet to be a clear strategy to support that activity. Networks hopes to use this pilot to inform possible approaches for private sector involvement in LLIN distribution. One effective way to implement a subsidy intervention is through the use of coupons. Ghana has piloted paper vouchers/coupons in LLIN distribution in the past. An e-coupon is conceptually similar to paper coupons but it differs in using a digital/electronic platform. This platform shift reduces large personnel involvement, improves efficiencies, and reduces fraud. An e-coupon issuing point (health clinic, workplace, church or other participating issuer) gives out a coupon with a discount code to a target beneficiary. The beneficiary can then redeem their coupon at a participating retailer for a net, paying only the top up. The retailer submits the code using their mobile phone and their account is credited. Issuing points are set up in the system with an appropriate discount based on the donor funding the subsidy (e.g. a workplace coupon discount may differ from a health clinic discount since the employer directly funds their own workplace coupon). The e-coupon database is able to track which issuers and retailers are issuing and redeeming e-coupons on a continuous basis. The pilot is designed to reach three different targets with varying levels of subsidies for LLINs. 1. The general population in Koforidua, a town in the Eastern region of Ghana with a population of

about 200,000, receiving varying levels of subsidy. 2. Workers of two selected large employers based in two separate locations, receiving varying levels

of subsidy. 3. School children in grades 3 and 5. School children will receive 100% subsidy, by determining with

the supplier a previously negotiated Cedi-denominated “manufacturer’s suggested retail price” that includes a retailer mark-up.

Results from this pilot will inform the scale-up of the e-coupon subsidy program in Ghana, as well as motivate other malaria endemic countries to adopt the strategy.

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Goals of the Pilot • Stimulate private sector investment in malaria control in endemic countries • Demonstrate viability of retail shops as LLIN distribution points for subsidized nets Pilot Implementation objectives • Create an e-coupon platform with capabilities of efficiently managing subsidies from multiple

donors, to a variety of target populations, with differing levels of subsidies for specific targeted populations.

• Create demand for subsidized LLINs in Koforidua and in the selected workplaces • Demonstrate a cost effective public private partnership to reach targeted consumers with

different levels of subsidies. The market participants • Networks Ghana – Networks supports the administrative and general management of this

project. Specifically, it has recruited and trained the coupon agents, is working with the manufacturer/distributor to recruit retail shops, assist with a marketing campaign, and through its technical partner MEDA manage the IT back-end to provide transactional data required for analysis of the market activity.

• Manufacturers & Distribution – For the initial pilot, NetWorks has partnered with the manufacturer(s)/distributor(s) that offers the most competitive cost structure; is willing to participate in promotional activities; and sees this as a long-term market opportunity, rather than a one-time sales campaign.

• Retail Shops –Potential shops for this pilot include pharmacies and drug shops. They must also have the ability to maintain records and use text capabilities on their mobile phones.

• Coupon issuing agents – Private medical clinics, workplaces, churches and selected primary schools are the coupon-issuing agents in this pilot.

Consultant Scope of Work 1. Conduct a process evaluation for the e-coupon program to assess the program objectives as they

are being implemented 2. Write a final report that:

1. Describes the current functioning of the e-coupon system, identifying strengths and weaknesses

2. makes recommendations for improving or streamlining the processes 3. makes recommendations for key considerations as the program is scaled up.

Key information and indicators to collect 4. Document program efficiency in terms of:

a. Total numbers of LLINs distributed to identified target beneficiaries; b. Average cost per net delivered to a beneficiary, as well as individual cost components

along the supply chain; c. Time and effort required on stakeholders’ part (retailers, coupon issuers,

manufacturer/distributer, recipient) to participate in the program d. Describe challenges, bottlenecks and other hindrances from stakeholders’ perspectives

that impact the smooth running of the program

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5. Document program effectiveness in terms of: a. Proportion of selected target populations reached through this system, based on

administrative data; b. Redemption rates of coupons issued, by target population c. Willingness of participants in the system (coupon distributors, LLIN retail distributors,

LLIN wholesale distributor(s), donors and beneficiaries to continue participation; 6. Develop recommendations for scale-up, based on problems encountered and potential

solutions/changes needed. Methods: We envision two data collection methods will be needed to acquire the program implementation process data: 4. Data collected in the program management process and captured by either the computerized

transactions, such as the number of coupons issued by coupon distributors, number of coupons redeemed by each LLIN distributor, the monetary value of the payments to each LLIN distributor; or by routine reporting such as the number of coupons/nets delivered to each coupon/LLIN distributor through the course of the pilot study.

5. Interviews with those participating in the program about their experiences. This includes: a. Private sector donors (international donors and participating employers) b. Pilot implementation staff (MEDA, NetWorks Ghana) c. LLIN wholesale distributer(s) d. Registered coupon issuers e. Registered retail outlet owners f. Consumers

i. Employees ii. General population

iii. School children (with their parents) in targeted classes

In these interviews we will ask donors, distributors, and retailers about how they perceive the program in terms of benefits to themselves, to their customers/clients/employees, whether they would continue to participate in such a program in the future, and why or why not. We will ask about problems they encountered in using the system, and what recommendations they would make for an improved program. During interviews with consumers we will ask them about their perceptions of the program, what amount they expected to pay to get a net, what amount they actually paid, and any challenges or confusion they experienced in the process of obtaining a subsidized net.

Interviews will use a discussion guide or questionnaire format, with some opportunities for short answer text responses. No personal identifiers will be collected from consumers, and distributors of coupons or LLINs will be identified only by their computer identification code used in the program.

Interviews will be conducted with:

1. Private sector donors (international donors) and employers: consultant will interview donor representatives, as well as CEOs or their designated representative in the 2-3 companies which participate as donors to the program.

2. Pilot implementation staff : consultant will interview the key personnel involved in the management and implementation of the pilot from MEDA and NetWorks Ghana

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3. Ministry of Health and Ministry of Education: consultant will interview selected officials from the Ministry of Health (at Koforidua level) and Ministry of Education (School Health Education Program coordinators) for their perspectives.

4. Wholesale distributors: consultant will interview all of the recruited into the program (this may be one)

5. Coupon Issuers: consultant will interview all of the 19 coupon issuers recruited into the program, including private health clinics, private hospitals, churches, and the initial activation/promotional team.

6. Net Retail Outlets: consultant will interview all of the 35 retail outlets recruited. 7. Consumers: consultant will conduct exit interviews with consumers as they leave LLIN

distribution points, with a target number of interviews of 20. We will interview up to 20 parents of school children with their child students either at the school or in their homes.

8. Employees: From employees who received an e-coupon through their employer, we will randomly sample up to 15 employees per workplace with short questionnaires at their place of work or in their homes, depending on approval by the employer to interview on the premises. Employer representatives would not be present in these interviews.

Timeline: Fieldwork for the process evaluation should take place in from November 17-December 7th, 2013, 6-8 weeks after the pilot begins in Koforidua, to allow mid-term corrections to take place in the pilot and to prepare recommendations for scale up. A debriefing will be scheduled with PMI, NMCP and stakeholders in Accra at the conclusion of the visit. We have allowed for 5 days of report writing following the visit to incorporate feedback from partners. This totals 26 days for the assignment. Logistics: A NetWorks Ghana staff member will assist in scheduling interviews, booking hotel rooms, and arranging transport. NetWorks will cover airfare, lodging and per diem for the consultant at US State Department rates and according to the JHUCCP Travel Policy. Deliverables:

1. Process evaluation report. An outline will be developed jointly prior to the assignment. 2. Presentation to be given to the NMCP at the conclusion of the visit with initial results and

recommendations. 3. Final discussion guides 4. Photographs of retail outlets, coupon issuing points, workplace issuing points, etc to

accompany the report Call for Consultants: Interested individuals should submit a CV and cover letter describing their relevant experience to Hannah Koenker (hkoenker@jhuccp.org) by October 25th 2013. Consultants should have experience in the distribution of LLIN and ideally in the evaluation of LLIN distribution programs. Experience in Ghana is a plus.

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Annex II: Work Plan Date Description Location KB JA AK/CV 13-Nov-13 Briefing of consultants by Networks HQ/Ghana teams Desk based X 14-Nov-13 Work plan development Desk based X X 15-Nov-13 Send work plan for review by Networks HQ/Ghana teams Desk based X 16-Nov-13 17-Nov-13 18-Nov-13 Review of background documents and development of evaluation tools Desk based X X 19-Nov-13 Review of background documents and development of evaluation tools Desk based X X 20-Nov-13 Review of background documents and development of evaluation tools Desk based X X 21-Nov-13 QA evaluation tools Desk based X 22-Nov-13 Finalise and submit draft evaluation tools for review by Networks HQ/Ghana teams Desk based X X X 23-Nov-13 KB travels to Ghana Ghana X 24-Nov-13 Internal (KB and JA) meeting Ghana X X 25-Nov-13 Meeting with Networks and finalisation of evaluation tools Ghana X X 26-Nov-13 Meeting with Networks and finalisation of evaluation tools Ghana X X 27-Nov-13 Trip to Koforidua and test of evaluation tools Ghana X X 28-Nov-13 Koforidua field interviews Ghana X X 29-Nov-13 Koforidua field interviews Ghana X X 30-Nov-13 Koforidua field interviews Ghana X X 01-Dec-13 KB travels back to Accra Ghana X 02-Dec-13 Koforidua field interviews Ghana X

Accra interviews Ghana X 03-Dec-13 Koforidua field interviews Ghana X

Accra interviews Ghana X 04-Dec-13 Koforidua field interviews Ghana X

Accra interviews Ghana X 05-Dec-13 JA travels backs to Accra / Internal (KB and JA) meeting Ghana X

Accra interviews / Internal (KB and JA) meeting Ghana X

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Date Description Location KB JA AK/CV 06-Dec-13 Internal (KB and JA) meeting / Debriefing with Networks Ghana team Ghana X X 07-Dec-13 KB travels back to UK Ghana X 08-Dec-13 09-Dec-13 Draft report Desk based X X 10-Dec-13 Draft report Desk based X X 11-Dec-13 Draft report Desk based X X 12-Dec-13 QA draft report Desk based X 13-Dec-13 Finalise and submit draft report for review by Networks HQ/Ghana teams Desk based X X X 14-Dec-13 15-Dec-13 16-Dec-13 17-Dec-13 18-Dec-13 Networks HQ/Ghana teams send collated comments 19-Dec-13 Discuss comments on draft report and finalise report Desk based X X 20-Dec-13 Discuss comments on draft report and finalise report Desk based X X 21-Dec-13 22-Dec-13 23-Dec-13 QA final report and submission Desk based X

KB Karen Bulsara JA Justice Ajaari AK / CV Albert Kilian / Caroline Vanderick

X Desk based days are not all full days of work, hence the total amount of days crossed for each consultant is higher than respective LoE

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Annex III: Data Collection Tools Questionnaires were developed using the following guides:

1. Pilot Implementation Team

Purpose of Interview: - To gain a full understanding of the LLIN e-coupon pilot program in order to inform the process

evaluation - To ascertain any implementation issues encountered and lessons learnt to inform scale-up - To highlight any limitations or areas of concern - To confirm the necessary systems are in place for e-coupon implementation at scale

Interview to cover: No. of Respondents - 6 Confirm Pilot Implementation Objectives and see if met, i.e. Pilot Implementation objectives

• Create an e-coupon platform with capabilities of efficiently managing subsidies from multiple donors, to a variety of target populations, with differing levels of subsidies for specific targeted populations.

• Create demand for subsidized LLINs in Koforidua and in the selected workplaces

• Demonstrate a cost effective public private partnership to reach targeted consumers with different levels of subsidies.

Specifically: Pre-Launch Activity:

• Brief evaluation of the pre-launch location and market research to determine demand, willingness to pay, etc. After all, the initial design included conducting a series of focus groups and market research. The absence of such research may have led to some flawed assumptions about demand and pricing.

Process: • How are monitoring systems working – fraudulent activities being detected?

• How is the mobile network uptime affecting the program? Other technology issues?

• What is the response time and are systems in place to respond to market actors?

• Are reports clear and scheduled to monitor progress – what is necessary for scale up?

• Relationship between MEDA and technology provider (SMSGH/) – implication of scale-up?

• Training – is this sufficient – is there on-going support provided?

• Logistics / transport issues?

• Review of Agrimat’s pricing structure; is Agrimat’s cost structure reasonable and competitive? In the case of the pilot, we were largely price takers, unaware of our net costs until the week of launch.

Pricing: • What considerations have been made to ensure equity in the project design and how will you ensure

that equity measurements will be possible once the program has gone to scale?

• Setting of subsidy for different targets audiences, how was this calculation made?

Demand Creation:

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• What demand creation efforts are being implemented?

• The marketing company’s marketing, demand creation and outreach campaign - hopefully including some analysis of the POP vs. other media effectiveness.

• Mass campaign (free LLIN distribution) completed at end 2012 – considered impact of this?

• Private Sector sales lagging behind in LLIN distribution – considered reasons for this?

Acceptability: • How has the program been received by the various actors?

• Perceptions of ease of use of system for market actors? Levels of satisfaction ?

Recommendations to improve program:

2. External Stakeholders:

Purpose of Interview: - To ascertain the level of understanding and commitment to the e-coupon program, as plans are made

for scale-up.

Interview to cover: No. of Respondents - 4 Intro:

Background to this pilot program Process Evaluation and potential scale-up Operating Environment in Ghana:

Mass campaign (free LLIN distribution) completed at end 2012 – considered impact of this? Private Sector sales lagging behind in LLIN distribution – considered reasons for this?

Potential for e-coupon program in Ghana: How does this pilot program fit into the overall national malaria control strategy? What is the level of management control at national vs regional levels? Coupon Program (as implemented in Tanzania) is considered a way to utilise the strengths of the private sector in LLIN distribution/sales – is this accepted wisdom – can it work in Ghana? How is the private sector viewed? Is it considered strong enough nationally? Networks hope to use pilot to inform possible approaches for private sector involvement in LLIN distribution – are there any expectations beyond an e-coupon program? Results of pilot to inform scale-up and to share lessons learnt for other country programs – how is the concept of scale-up viewed – regional, national, other etc?

Willingness to continue with program – reasons for or against? Recommendations to improve program? Awareness of de Savigny article, 2012 Contributors: Irene Akua Agyepong Ghana Health Service, Accra Constance Bart-Plange National Malaria Control Program, Ghana Health Service, Accra Aba Baffoe-Wilmot National Malaria Control Program, Ghana Health Service, Accra

3. Distributor Partner

Purpose of Interview: - To ascertain the level of effort and interest of this partner in the program.

Partner: Agrimat

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Interview to cover: No. of Respondents - 1 Intro:

Background to this pilot program Process Evaluation and potential scale-up Operating Environment in Ghana:

Agrimat does not operate in consumer retail markets and so is not ideally placed to develop the LLIN consumer market – own perceptions of fit for such a program? How has mass free distribution affected the private sector market for LLINs? Have you been involved in any planning at national level?

The e-coupon program in Ghana: What are the operating issues that have been encountered? Positives and Negatives? How easy has it been to adapt operations to accommodate the e-coupon program? Is there an interest and is there the capacity to operate at scale? What is the implication of opening up the program to other distributor partners? How has the “Payment system” worked? Are sales volumes sufficient for participation? Have demand creation efforts been satisfactory? Is the subsidised price low enough to entice new consumers? What are the difficulties in offering credit to retailers? Consideration of other possible distributor partners e.g. pharma, bedding etc What successes have come from this program for your business?

Willingness to continue in program – reasons for or against? Recommendations to improve program?

4. Technology Partner

Purpose of Interview: - To ascertain the level of effort required for participation in such a system and understand any issues

for scale-up

Partner: SMS Ghana (Nana Kwame) Interview to cover: No. of Respondents - 1 Intro:

Background to this pilot program Process Evaluation and potential scale-up Operating Environment in Ghana:

Details about mobile network in Ghana and ease of operation? Dealing with current level of mobile business interactions? Do you have the capacity for scaling up program? Acceptability of e-coupon use in Ghana?

Partnership Issues: Working relationship with MEDA Willingness to continue in program – reasons for or against

The Pilot Program: Are there any aspects of the pilot program that have worked better than expected; or have caused more problems than expected? Implications of this for scale up? Is there sufficient capacity amongst the population to successfully utilise the e-coupon for LLINs at issue and at redemption?

Recommendations to improve program? Possible Technological Advances:

Launch of additional SMS short codes (beyond the 4 current providers) Additional technological advances e.g. limiting no. of vouchers per customer; self-issue

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5. Employer Program

Purpose of Interview & Questionnaire Survey: - To see how the employer program has been operating for all actors:

a. Plantation Owners: i. VREL (400 employees)

ii. Golden Exotic (2500 employees) b. Plantation e-coupon issuers c. Plantation Employees (recipients)

- To see if there are any issues for Plantation Owners in signing up to such a scheme - To see if there is any implementation issues for coupon issuers - To see how acceptable the program is to recipients/employees

Owner Interview to cover: No. of Respondents - 2 Intro:

Background to this pilot program Process Evaluation and potential scale-up Benefits of e-coupon scheme:

What are the benefits to the company in being part of this scheme? Any problems? What are the benefits of LLINs and benefits of reduced price with e-coupon for employees?

Process: Ability to use e-technology for issuers and employees? Are Issuers motivation levels high – understanding of the wider program goals?

Pricing: Expected price of LLIN and price actually paid – perception of subsidy level? Ability and willingness to pay amongst employees?

Demand Creation: Implications of the recent mass campaigns free nets on perceived value of LLINs? Is there sufficient demand creation to stimulate participation in the program?

Acceptability: Acceptability of program to the company and amongst employees?

Continued Support: Willingness to continue in program – reasons for or against

Recommendations to improve program? Questionnaires for Issuers to cover: No. of Respondents - 2 Promotion of LLINs and e-coupon Subsidy:

Can you relay benefits to employees of LLIN and benefits of reduced price with e-coupon? Expected price of LLIN with e-coupon – perception of subsidy – is it adequate? Are there any implications of the recent mass campaigns on perceived value of LLINs?

Process: Acceptability of e-technology amongst employees? Ease of system for issuers of e-coupons / use of technology? Motivation levels of issuers – understanding of the wider program goals?

Willingness to continue in program – reasons for or against? Recommendations to improve program? Questionnaires for Employee Recipients to cover: No. of Respondents - 10 Current Net Purchase and Use:

How many nets that you own have been given free / bought? Is the net actually used – perceptions of malaria risk?

Promotion of the LLIN e-coupon scheme: How/where did you hear about the reduced price nets? Understanding of benefits of LLIN and benefits of reduced price with e-coupon?

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How do you feel about your employer participating in this program? Process:

Perceptions of the subsidy program? Does the e-coupon make you want to buy a net? Acceptability of e-technology? Any issues in obtaining an e-coupon from issuer? e.g. trust, access, need for ID cards etc Reasons for not participating? E.g. free net distribution, other? Any issues in obtaining a subsidized LLIN from retailer? e.g. need for ID cards Would you get your own e-coupon on your cell, if you saw it advertised or do you prefer someone you trust to do this for you?

Pricing: Expected price of LLIN and actual price paid for LLIN? Is the subsidy motivating enough for you to purchase an LLIN? Reasons for not purchasing e.g. price, access, no supply, trust e-system, network problem etc

Program Improvements: What improvements could be made that would make this work better for you?

6. Schools Program

Purpose of Interview & Questionnaire Survey: - To see how the school program has been operating for all actors:

a. Secondary School Principals i. Pope John’s

ii. Oyoko Methodist Senior High iii. Ghana Secondary

b. Primary School Prinicipals i. Nana K Boateng

ii. Riis Presby iii. Presby

c. School e-coupon Issuers d. Schools (Parents) recipients

- To see if there are any issues for School Principals in signing up to such a scheme - To see if there is any implementation issues for coupon issuers - To see how acceptable the program is to recipients/parents of school children

School Principal Interview to cover: No. of Respondents - 6 Intro:

Background to this pilot program Process Evaluation and potential scale-up Benefits of e-coupon scheme:

What are the benefits to the school in being part of this scheme? Any problems? Understanding of benefits to children of LLIN use and benefits of reduced price with e-coupon?

Process: Acceptability of and ability to use e-technology for issuers and children/parents? Are Issuers motivation levels high – understanding of the wider program goals?

Pricing: Expected price of LLIN and price actually paid – perception of subsidy level? Ability and willingness to pay amongst parents of school children?

Demand Creation: Implications of the recent mass campaigns free nets on perceived value of LLINs? Is there sufficient demand creation to stimulate participation in the program?

Continued Support: Willingness to continue in program – reasons for or against?

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Recommendations to improve program? Issuer Questionnaires to cover: No. of Respondents - 6 Promotion of LLINs and e-coupon Subsidy:

Can you relay benefits to community of LLIN and benefits of reduced price with e-coupon? Expected price of LLIN – perception of subsidy – is it adequate? Implications of the recent mass campaigns free nets on perceived value of LLINs?

Process: Acceptability of e-technology amongst children and parents? Ease of system for issuers of e-coupons / use of technology? Motivation levels of issuers – understanding of the wider program goals?

Willingness to continue in program – reasons for or against? Recommendations to improve program? Focus Group for Parents to cover: No. of FGDs – 2 Current Net Purchase and Use:

How many nets that you own have been given free / bought? Is the net actually used – perceptions of malaria risk?

Promotion of the LLIN e-coupon scheme: How/where did you hear about the reduced price nets? Understanding of benefits of LLIN and benefits of reduced price with e-coupon? Perceptions of the program and child’s participation in it? How do you feel about your school participating in this program? Perceptions of the subsidy program? Does the e-coupon make you want to buy a net? Understanding of benefits of LLIN use for children and benefits of reduced price with e-coupon?

Process: Any issues in obtaining an e-coupon from the school? e.g. trust, access etc Reasons for not participating e.g. perceptions of political associations for voter appeasement, free nets? Acceptability of e-technology? Would you get your own e-coupon on your cell, if you saw it advertised or do you prefer someone you trust to do this for you?

Pricing: Expected price of LLIN and actual price paid for LLIN? Any issues in obtaining a subsidized LLIN from retailer? E.g. need for ID cards Reasons for not purchasing? e.g. price, access, no supply, trust e-system, network problem etc

Recommendations to improve program?

7. General Population

Purpose of Questionnaire Survey: - To see how the general population have received the e-coupon program and how easy it was to utilise

No. of Respondents - 30

Current Net Purchase and Use: How many nets that you own have been given free / bought? Is the net actually used – perceptions of malaria risk?

Promotion of the LLIN e-coupon scheme: How/where did you hear about the reduced price nets? Understanding of benefits of LLIN use and benefits of reduced price with e-coupon?

Process: Perceptions of the subsidy program? Does the e-coupon make you want to buy a net? Any issues in obtaining an e-coupon from issuer? e.g. trust, access, need for ID cards etc

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Reasons for not participating e.g. perceptions of political associations for voter appeasement? Acceptability of e-technology? Would you get your own e-coupon on your cell, if you saw it advertised or do you prefer someone you trust to do this for you?

Pricing: Expected price of LLIN and actual price paid for LLIN? Any issues in obtaining a subsidized LLIN from retailer? E.g. need for ID cards Reasons for not purchasing? e.g. price, access, no supply, trust e-system, network problem etc

Recommendations to improve program?

8. Issuers

Purpose of Questionnaire Survey: - To see how the general e-coupon program has been operating for all actors:

a. e-coupon Issuers i. Clinics

ii. Hospitals iii. MTN Mobile Credit Vendors iv. Post Offices v. Community Centres

b. Recipients - To see if there are any issues for community leaders in recommending such a scheme - To see if there is any implementation issues for coupon issuers of differing types

- To see how acceptable the program is to recipients/general population

Issuer Questionnaires to cover: No. of Respondents - 25 (5 of each issuer type): Promotion of LLINs and e-coupon Subsidy:

Can you relay benefits to community of LLIN and benefits of reduced price with e-coupon? Expected price of LLIN – perception of subsidy – is it adequate?

Process:

Acceptability of e-technology amongst different target groups? Ease of system for issuers of e-coupons / use of technology? Motivation levels of issuers – understanding of the wider program goals? Implications of the recent mass campaigns free nets on perceived value of LLINs?

Willingness to continue in program – reasons for or against? Recommendations to improve program?

9. Redemption Points (Retail Outlets)

Purpose of Questionnaire Survey: - To ascertain how successfully the e-coupon system has worked and the whether the private sector

retailers have been stimulated to participate in the program

Type of Outlet: a. Pharmacy

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b. Drug Shop c. Supermarket d. High School (not a retail environment?)

Questionnaires to cover: No. of Respondents – 35 (7 of each outlet type) Sales Rate:

Redemption rates – how many nets are you selling? Impact of e-coupon on business and sale of LLINs?

Process: Ease of redemption system? How do you purchase from supplier, in what quantities, do you need credit facilities? Use of the mobile technology for subsidy – network issues? Location of redemption point to issue point? Competition with other providers?

Demand Creation: Understanding of benefits of LLIN use and how successfully this is communicated to customers? Need for BCC and consumer awareness communications/campaigns? Suitability of LLIN product for the market / demand?

Customer Perceptions: Do you believe customers value the e-coupon price reduction on LLINs? Reasons for answer?

Benefits of remaining in program: Willingness to continue in program – reasons for or against? Perceptions of viability of the program in current market – volumes sold, implication of free net distribution etc?

Recommendations to improve program?

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Annex IV: Sources of Information List of documents reviewed Journal Articles: • Introducing vouchers for malaria prevention in Ghana and Tanzania: context and adoption of

innovation in health systems; de Savigny, D. et al; Health Policy and Planning 2012

• Lessons in Brief No. 7 Tanzania: Making Targeted Subsidies Fast and Flexible. The TNVS eVoucher, RBM, UAID, NetWorks, 2013

Project Reports / documents: • Agrimat Retailer memo Agreement

• Contact Sheet Retailer – School e-coupons

• e-Coupon performance Oct 11 2013

• e-Coupon Retailer Payment Report

• Fiona Mackenzie e-Coupon Trip Report

• GH e-Coupon ITA (Fiona)

• GH e-Coupon ITA (Lauren)

• Ghana e-Coupon Gantt 12.07.13

• Ghana e-Coupon Implementation Plan

• Ghana Net Project Posting Advertisement

• Ghana Issuers List

• Ghana Retailers List

• Monthly Activity Schedule Nov

• Notes on e-Coupon

• Payment Report 4 (Oct 29)

• Payment Report 4 (Nov 8)

• Primary 4 Enrolment detail

• Progress Report (14.10.13)

• Sales Report (Nov 9-15)

• Updated list of e-coupon retailers

• VREL Letter

• Weekly updates (week 4445)

• Weekly updates (wee 4041)

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List of persons interviewed

Person Designation JK Ofori NetWorks Ghana Chief of Party Felix Nyanor-Fosu NetWorks Technical Director Samuel Seddoh MEDA eCoupon Project Coordinator B Acheampong Regional Education Directorate, K’dua Prosper Agbagbah Regional Public Health Office, K’dua Shamwill Issah Health Adviser, DFID Dr Sureyya Hornston PMI Technical Adviser, USAID Kate Opoku SHEP, Ghana Education Service Nana Kwame Adu-Gyamfi SMS Ghana Adjoa Ahulu Client Service Director Multiple Concepts Charles Srem-Sai Salesman, Agrimat Mr Nana Yaw Managing Director, Agrimat Araba Sam Annan Health Alliance Network Ghana (VF) Adjo Mfodwo Regional Manager, Bayer Joe Ampem-Darko Antwi Communications Manager, Ashfoam Alex Yeboah-Afari HR Manager, Volta River Estates Constance Bart-Plange Manager, NMCP, Dept of Health Aba Baffoe-Wilmot Medical Entomologist, NMCP Thom Dixon MEDA Jerry Quigley MEDA Fiona Mackenzie MEDA Lauren Good MEDA

Koforidua Respondents:

Issuing Outlets: CICs 1. Sushyen Community Information Centre (CIC), Sushyen

2. Jumapo Community Information Centre (CIC), Jumapo Clinics 1. Rabito Clinic, Koforidua SSNIT

2. Patbrenda Clinic, Koforidua SIC 3. Bona Clinic, Koforidua Market Area 4. Dr. Asomani Clinic, Koforidua Town 5. Providence Medical Centre, Koforidua-Abogiri

Hospitals 1. St. Joseph Hospital, Koforidua-Effiduase Mobile Phone Vendors

1. Hamdallah Communication and Business Centre, Koforidua Zongo 2. Benscom Ventures (MTN) Vendor, Koforidua Market Area 3. Prince Mobile Phones, Koforidua Effiduase 4. Effiduase MTN Vendor, Koforidua Effiduase

TOTAL 12 Redemption Outlets: Pharmacies 1. Adbest Pharmacy, Koforidua Effiduase

2. Inter Pharma, Koforidua Effiduase 3. Amiscus Pharmacy, Koforidua Effiduase 4. Wesley Pharmacy, Koforidua Srodae 5. N.K. Darko Pharmacy, Koforidua Regional Hospital 6. Drugrite, Koforidua Antartic

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7. TC Pharmacy, Koforidua SIC Chemical Shops

1. Agartha Dwumfour Chemical Shop, New Asokore 2. Clifford Sefa Chemical Shop, KOSEC Boys Hostel in Koforidua 3. Abundant Grace Chemical Shop. Effiduase in Koforidua 4. Amazing Grace Chemical Shop, Oyoko, outside Koforidua 5. Odame Boamah Chemical Shop (Wofa Drug Store), Asokore 6. Akomeah Chemical Shop, Adweso Market in Koforidua 7. Mandacliff Chemical Shop, Effiduase in Koforidua 8. Convenant Chemical Shop, Oyoko, Outside Koforidua

General Stores 1. Adwoa Adongo Corner Shop, Koforidua Magazine 2. School of Technology (Herbal Shop & Internet Café, Effiduase 3. Corner Shop Lucy, Effiduase

TOTAL 18 Secondary Schools: 1. Pope John’s Secondary School (POJOSS)

2. Ghana National Secondary School (GHANASS) 3. Oyoko Methodist Secondary School (OMESS)

TOTAL 3 Primary Schools Meetings with Parents: 1. Presbyterian Primary School, Koforidua 2. Nana Kwaku Boateng Primary School, Koforidua TOTAL: 2 Employer Program: TOTAL 10 VREL Field Worker Employees Promoters: TOTAL: 3 from Multiple Concepts October launch activity General Population: TOTAL 30 (telephone interviews)

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Annex V: Tables for eCoupon Issue by Issue Point and eCoupon Redemeption by Outlet eCoupon Issues by Issue Point

Issue Point Issued Redeemed %Rdm

Health Shops:

Agyemax Health Shop 4 0 0% Internet Cafes:

Babs internet Cafe 2 0 0% School of Information Technology (ICT

Centre) 13 0 0%

Hamdallah Communication Centre 4 2 50% Mobile Phone Credit Vendors:

Benscom Ventures 5 3 60% Gifty Amegatse- Opp Reg. Hospital 4 2 50%

Good News Enterprise 9 2 22% Prince Phones (Fear Not phones) 11 7 64%

Private Clinics/Hospitals: Bonna Clinic 53 41 77%

Dr. Asomani's Clinic 21 0 0% Eunice Memorial Clinic 10 6 60%

Koforidua Clinic 17 15 88% Oman Clinic 24 1 4%

PatBrenda Clinic 10 2 20% Pat's Maternity Home (Mother) 16 7 44%

Providence Hospital 54 7 13% Rabito Clinic 10 4 40%

St. Joseph's Hospital 56 35 63% Sutton Clinic 5 2 40%

Community Information Centres: Community Information Centre Suhyen 20 8 40%

Jumapoman Information Center 2 0 0%

Post Offices: Ghana Post- Oyoko 5 2 40%

Secondary Schools: Ghana Sec. School- K'dua 39

Oyoko Methodist Senior High School 109 47 43% Pope John's Sec. School 52 29 56%

Primary Schools:

Primary School Program 530 263 50% Employers:

VREL (Employer Program) 5 0 0% Promotions:

Multiple Concepts (Initial Distribution) 1,171 54 5% Grand Total 2,261 539 24%

without Multiple Concepts promo issue: 991 314 32%

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e-Coupon Redemption by Outlet

Outlet Gen Pop Prim Sch Total %

PHARMACIES: Ad Best Pharmacy 9 1 10 2% Amicus Pharmacy 5 17 22 3% Drug Rite Pharmacy 17 13 30 5% Eastern Chemist 3 45 48 8% Gabson Pharmacy 18 18 3% Interpharma 17 24 41 6% T.C Pharmacy 12 25 37 6% Wesley Pharmacy 9 69 78 12% 284 45% GENERAL STORES: Afua Tiwaa Supermarket 6 6 1% Antie Barbara Shop 3 3 0% Doris Adjei Retail 32 32 5% Krakue Store 1 1 0% Siaw Textile Distribution 9 35 44 7% 86 14% CHEMICAL SHOPS: Akumea Chemicals 1 16 17 3% Amazing Grace Chemicals 21 21 3% Clifford Sefa Chemicals 3 3 0% Covenant Chemicals 3 3 0% Eye Awurade Chemicals 8 8 1% Good Shepherd Chemical Shop 11 3 14 2% Grace Boateng Chemical 10 10 2% Manda Cliff Chemicals 9 1 10 2% N.K Darko Chemicals 7 12 19 3% Odame Boadu Chemicals/Wofa Yaw Drug Store 5 5 1% Segbefia Chemicals 3 2 5 1% 115 18% SECONDARY SCHOOLS: Ghana Secondary School (Secondary School eCoupons) 37 - 37 6% Oyoko Methodist Senior High (Secondary School eCoupons) 82 - 82 13% Pope John's Secondary School (Secondary School eCoupons) 29 - 29 5% 148 23% Grand Total 370 263 633 100%

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Annex VI: Scripts for Radio Advertisements and selected Airtime schedules (2 of 4) MEDIA: RADIO 60 sec TITLE: NIGHT TIME DRAMA Sfx: women’s laughter Fvo2: eii things can happen when you sleep oh. FVO: It was not easy at all especially when I felt the cockroach on my nose. Ah! Sfx: laughs. Fvo2: oh what about Aunty Ama’s experience, a rat had the audacity to kiss her, can you imagine that? Sfx: women laugh as some utter sounds of disgust. Fvo: is that why they call her ‘Ekura hemaa’ Sfx: laughs. FVO3: But the worst of them all is that night time mosquito, who senses when you are asleep and make s your ears a singing disco, and it won’t stop at that, you become dinner at the same time. Ah! Fvo2: that is true oh, and no matter how you try to swat it, you can never get it…. Sfx: laughter fades into background. AVO: Now with 7ghana cedis off all ‘donkomi’ DAWA mosquito nets your night time drama’s can come to an end. Residents of Koforidua Just look out for the bright yellow and blue donkomi sign at St Josephs Hospital and PROVIDENCE hopsital, participating private clinics and midwifery’s or churches; present your NHIS card or voters ID and then bingo! You qualify for a discount coupon. Present the coupon at any participating sales point in Koforidua and get your treated ‘DAWA’ mosquito nets whiles stocks last. Get your Long Lasting Insecticide treated nets NOW! ‘Men gya gya wo ho’ you might not get it like this again. MEDIA: RADIO 60 sec TITLE: ADVANTAGE. Sfx: knocking sounds. Fvo: ago! Kokoko! Aha! Mercy, please can you lend me some mosquito repellant for the children, I forgot to get some last week. Fvo2: repellant! In this Koforidua. (Laughs) ah Ama paa, haven’t you heard of the DAWA mosquito net donkomi right here in koforidua? Fvo: DAWA? FVO2: my sister, once you are a resident of Koforidua you can enjoy 7ghana cedis off all DAWA treated mosquito nets. It’s easy. All you have to do is look out for the bright yellow and blue donkomi sign at St Josephs Hospital and PROVIDENCE hospital, participating private clinics and midwifery’s or churches; present your NHIS card or voters ID and then bingo! You qualify for a discount coupon. Present the coupon at any participating sales point in Koforidua and get your DAW treated mosquito nets at a discount! My sister with long lasting treated mosquito nets at this amazing discount, the offer will not last long oh. Fvo: eii then now, all the children can have their own mosquito nets whiles kodwo and I share the one we already have. Ah! We can finally sleep in peace. AVO: Get your discount coupon from an agent near you and get your DAWA treated mosquito nets at a discount. ‘Men gya gya wo ho’ you might not get it like this again. Koforidua Mosquito…NTUMTUM HC AKYERENO at a discount.

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Annex VII: Employer Program Materials

Employee Circular, issued by the Plantation Employer, VREL, December 2013

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Annex VIII: Summary of Voucher Comparison Article* Summary of Key Issues for Successful Implementation:

1. Contextual Requirements 2. Long term stakeholder engagement 3. Alignment for single delivery system 4. Local stakeholder management of program

ISSUES AFFECTING SCALE-UP & SUSTAINABILITY*:

TANZANIA GHANA OBJECTIVES & SCALE:

To increase coverage in all regions, nationally To scale up to 7 of the 10 regions only (due to differences in economic context, no pvt sector used in N – lacked faith in pvt sector delivery) Adds complexity to program mgmt

ALTERNATIVE DELIVERY SYSTEMS: Social Marketing began in 1997 Social Marketing (SM) began in 1998 SM in 2002 generic promotion of all pvt sector nets in preparation for TNVS

SM Project finished after 3-4 years only. 3 new strategies adopted – none using pvt sector e.g. ANC prog directly competing with voucher pilot

NATURE & RESPONSE OF PRIVATE SECTOR Converted textile mills to net production (formal) SM engagement assisted this - primed market

No conversion of textile mills to nets. Only local small-scale informal market, not engaged

Concerted stakeholder management, consistently including private sector e.g. taxes and tariffs removals etc

Only one major agricultural distributor who also distributes ITNs (different supply chain to informal sector – agricultural vs textile supply chain)

Existing functional private sector system of ITN supply Need for whole new system of ITN supply Voucher appropriate for flourishing private market Distributors had limited resources and limited capacity to

buy in bulk. Long lead times to import nets in-country, so slow response to demand Therefore loss in trust by public sector in private sector ability to respond

STEWARDSHIP & GOVERNANCE Indigenous idea - out of challenge of NMCP to malaria community. Locally owned

Driven by external partners – based on Tanzanian idea

Design spanned years – put in structural change to manage program etc

Design only spanned months by one external partner. Insufficient attention to local informal commercial sector in Ghana

One single strategy One amongst several delivery strategies being tested Donors aligned behind TNVS Increasing no of parallel systems, funded by different

partners – complex and fragmented scene Pilot implemented by researchers – impt evidence base. Centrally coordinated

Pilot implemented by agents of donor partners and Regional Health Directors – small role for public sector

Alignment to common national approach across all regions

Series of extended pilots – confounded by other delivery models – confusing partners

Social Marketing developed and strengthened trust in private sector over time and primed market

SM did not have same effect here – private sector more fragmented and unpredictable – unmanaged complexity

*Source: Introducing vouchers for malaria prevention in Ghana and Tanzania: context and adoption of innovation in health systems; de Savigny, D. et al; Health Policy and Planning 2012

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COMPARISON BETWEEN TANZANIA AND GHANA VOUCHER PROGRAMS RESULTS*: TANZANIA GHANA

CONCEPTION PHASE: Early multi-stakeholder meetings to decide introduction of program in 1996

Suggested by DFID and USAID consultants in 2003. Partnership Task force formed – decide to pilot in 1 region but for only central and south regions (not national programme)

PILOT PHASE: SM & vouchers large scale pilot in 1997-9

(i) SM built trust and capacity of private sector & culture of net use over 6 years

Local capacity development (ii) 4 local manufacturers with govt backing)

Local leadership, local ownership (iii) strong research capacity (iv) common health policies across districts (v) donor partnership aligning to one strategy

SM (GSMF) 1998-2002 in only 10 regions Pilot began April 2004 in Volta region. 8 months later expanded to Eastern region. Led by Regional Health Directorates Management agent EXP Momentum contracted by USAID. All ITNS imported by international manufacturer Required local wholesalers to carry sufficient stock – therefore supported by USAID with stock advance money. DFID gave extra to expand coverage. 4 changes of design during pilot.

1. Int Manuf est’d warehouse in Accra with GFTAM funds

2. Distributor contracted to take nets from CMS to regions (same as Manuf)

3. One delivery point – salesperson with umbrella, decided by distributors

4. Introduced a 6 month voucher scheme in Accra and Ashanti - large demand meant insufficient supply for other regions – system could not work – loss of trust between public and private sectors.

DESIGN PHASE: Long design phase period 1999-2004 Wide participation 40 stakeholders Including local manufacturer In 2006 60 stakeholders convened by NMCP Agreement for aligning to single strategy Funding GFATM NMCP ITN cell coordinated all activities with key partners

Voucher scheme design by Netmark (USAID) in 2003 (brief period compared to Tz) Agreed amongst partners to have voucher pilot in Volta & E – for scale up to C & S; UNICEF prog in N etc. 5 year planning cycles 2004-8 funding on region by region basis. Pilot supported by EXXON Mobil for 6 months in 2004; and 2 other regions for 6 months in 2006 Planned for GFATM by 2007.

IMPLEMENTATION PHASE: Began 2004 – present day as a PPP One Tz manufacturer distributes all nets (as of 2013 going to introduce a 2nd distributor) NGO sector manages demand creation & BCC Public sector interface with clients NATNETS steering committee New donors: USAID, PMI, CDC Continuous evaluation – leading to efficiencies and innovation i.e. e-voucher NATNETS coordinate with mass distribution (free) catch up campaigns.

No aim for national scale coverage (7 southern regions) DFID funding withdrawn – for GFATM to take up Scale up in 2006 to Ashanti & Brong-Ahafo Scale up in 2008 to Central

*Source: Introducing vouchers for malaria prevention in Ghana and Tanzania: context and adoption of innovation in health systems; de Savigny, D. et al; Health Policy and Planning 2012