Intervention setting

In Ghana, household ownership of at least one ITN has steadily increased from 19% in 2006 to 74% in 2019 through the use of complementary channels: continuous distribution through antenatal clinics (ANC), child welfare clinics (CWC) and school-based distribution, and mass distribution campaigns. Fewer than 2% of ITNs in households in 2019 were from a retail outlet [25]. During the 2018 mass campaign, many individuals in urban settings refused to take the nets when they were offered, suggesting dissatisfaction with the net types offered [26].

The majority of PSMP activities focused in the urban areas of the Ashanti, Central, Greater Accra, and Western/Western North (previously Western region, prior to 2019 administrative restructure) regions of Ghana. These were chosen based on the higher presence of target customers for retail sector LLINs, that is, middle-class families with sufficient purchasing power to buy their own LLINs of different designs to the free nets offered through mass campaigns [27]. The long-term vision for the project was that reducing public sector investment in free LLINs to upper-income urban households would improve equity in ensuring resources for higher-risk, lower-income and rural households.

Intervention description

The PSMP project was implemented between July 2016 and June 2019 and involved four areas of activity: supporting the retail sector; supporting workplace partnerships for malaria prevention; advocacy and resource mobilization; and central management and co-ordination (Table 1).

Table 1 Timeline for main PSMP activities by project component

Supporting the retail sector

These activities aimed to develop a sustainable retail market for LLINs in Ghana. In the absence of local LLIN manufacturers, engagement with international LLIN manufacturers resulted in Memorandums of Understanding being signed with three in-country distributors of three international LLIN manufacturers.

Major activities under this component were thorough baseline and endline market analyses to provide the retail sector with reliable and current market information, and a human-centred design study to understand consumer design preferences and willingness-to-pay for non-standard LLINs, with the aim of stimulating private sector involvement and investment. Details of the methods and findings of these studies are provided elsewhere [27,28,29,30].

PSMP facilitated the business planning and financed LLIN seed stock for two partner distributors (worth around USD 75,000 per distributor). This was a one-time start-up grant for LLIN seed stock procurement to stimulate a steady supply chain for institutional and retail sales of WHO-approved LLINs, and to reduce distributor cash flow risks associated with retail distribution. PSMP worked with an advertising agency in Ghana to develop the comprehensive generic LLIN demand creation “NetLife” campaign to support retail sales, including print, radio, TV and social media advertising. The NetLife campaign was officially launched in March 2019, complemented by mini market activations in the three regional capitals.

Supporting workplace partnerships for malaria prevention

PSMP engaged with registered companies and agricultural co-operatives to promote enrolment in the Malaria Safe workplace initiative, a formalized system of malaria prevention support. As part of Malaria Safe, PSMP conducted the following activities:

  • Facilitated procurement of LLINs through partner distributors for distribution to employees, co-operative members or adopted communities. Subsidies of 20% for private companies (excluding those in the oil, extractive industries and financial sectors) and 40% for agricultural co-operatives were available for the first year of their participation. Costs of distribution to individual recipients were paid by the workplace partner, however technical assistance for LLIN distribution was provided by PSMP where needed.

  • Developed and produced factsheets and briefs on the health and business benefits of malaria prevention.

  • Facilitated seminars for senior staff and management, and employees to stimulate the interest of companies to invest in malaria prevention activities, and specifically LLINs.

  • Trained workplace malaria peer educators to serve as malaria champions within companies to carry out malaria prevention education, primarily in the use and care of LLINs.

  • Developed, introduced and provided technical support on a web-based Dashboard for companies to monitor malaria data, including LLIN purchases and absenteeism numbers.

By the end of PSMP, 50 workplace partners had signed up to the Malaria Safe workplace initiative.

Advocacy and resource mobilization

PSMP worked with existing malaria advocacy stakeholders to develop high-level advocacy activities and events. An Advocacy Advisory Council was developed, consisting of high-level media, public relations, private sector, government and non-governmental organization leaders. Advocacy activities included engagement with companies and agricultural co-operatives through promoting the Malaria Safe workplace initiative in their national or regional association meetings; raising the media profile of private sector involvement in malaria prevention; and recognition of Malaria Safe partners through high profile award ceremonies.

PSMP also worked closely with the national malaria control programme (NMCP) supporting broader resource mobilization goals, including increased domestic resources through the government and private sector. As such, PSMP supported the RBM Partnership and African Leaders Malaria Alliance (ALMA) efforts to revitalize the Ghana Malaria Foundation (GMF), which aims to raise resources for malaria interventions, and the development of an updated Resource Mobilization Strategy for Malaria Control and Elimination (2019–2023). The Resource Mobilization Strategy was validated in May 2019 and includes objectives on the market development approach for malaria commodities.

Central management and co-ordination

Members of the core project management team spent time on cross-cutting project or financial management activities necessary for coordination of the project as a whole.

Framework for costing analysis

The PSMP project was a catalytic intervention to invigorate private sector investment in malaria prevention. Therefore, although the project’s costs were incurred over 3 years, relatively few of the benefits were realized within this same time-period; the main benefits are expected to continue and build over a longer timescale. A cost-consequences framework was used to map out the catalytic intervention costs to different stakeholders and the projected consequences of the intervention (Fig. 1).

Fig. 1
figure 1

Cost-consequences framework for the Private Sector Malaria Prevention project. This provides the analytical framework for the consequences included in the catalysed expenditure analysis. Intermediate outcome and impact measures were not included

In brief, catalytic costs of the intervention are presented from the donor perspective. Costs to other stakeholders are considered as consequences of this catalytic investment and include: workplace partner costs of malaria prevention activities; household costs in purchasing LLINs from retail outlets; domestic resource mobilization in terms of increased public sector financing as well as financial contributions for malaria control by private investors. The time horizon for projecting catalysed expenditure is 5 years following the end of the PSMP project, balancing sufficient time for the benefits of the intervention to be realized with the increasing uncertainty of assumptions around such benefits too far into the future. Some of these cost and consequences data could be collected empirically, whilst for others it was not possible, either due to limited funding for the evaluation or because the consequences were too far in the future. Where appropriate, estimates were taken from the published literature or programme documents and alternative scenarios constructed to explore uncertainty around future consequences of the intervention.

Final health and economic outcome and impact consequences further downstream of the initial catalytic investment are not included in this analysis which focuses on the intermediate consequences that could feasibly be achieved within 5 years of project end. For example, cost savings due to reduced malaria morbidity and mortality that result from increased LLIN ownership and use, or the economic benefits arising from reduced work and school absenteeism and increased productivity are not included (Fig. 1).

Financial and economic costs to the donor

A top-down approach was used to identify all resources required to deliver the PSMP project interventions from the donor perspective [31]. Financial costs were obtained retrospectively from the project financial reports and accounts in Ghanaian Cedi (GHS) or United States Dollars (USD), for 3 years of intervention implementation (July 2016–June 2019).

Time spent by the Ghana- and US-based team on the four areas of project activity were estimated by individual team members each project quarter and salaries allocated proportionally. Shared costs such as office equipment, office rent, office furniture and utilities were classified as overheads and allocated across the four areas of activity proportionally to personnel time, separately for the Ghana and US teams. In Ghana, office space and capital equipment, including vehicles was shared with another project and 50% was charged to the PSMP project before allocating to specific activities.

In-depth interviews (IDIs) were conducted in July–August 2019 with stakeholders involved in PSMP-supported activities from the public sector (including members of the NMCP) and those involved in malaria advocacy (n = 3) to capture any financial or economic resources provided to PSMP-supported activities from the public sector perspective and the time commitment involved for participation in membership of the Advocacy Advisory Council, respectively.

Value of private and public expenditure catalysed by donor investment

Financial costs incurred by workplace partners were obtained from the PSMP Dashboard, a database used by workplace partners to record expenditure on LLINs, LLIN distribution, behaviour change communication (BCC) and other malaria prevention activities. To validate the Dashboard data, estimate time spent on PSMP-related activities and gather perspectives on the sustainability of malaria prevention activities post-PSMP, IDIs were conducted in July–August 2019 with a sub-sample of these institutional partners (31 interviewees from 16 companies).

Costs to retail sector stakeholders (manufacturers, distributors, retail outlets) were not included in the analysis as it was assumed that their costs were fully recovered through profit margins applied along the supply chain. However, two PSMP partner distributors were interviewed to gather their perceptions on the sustainability of a private market for LLINs in Ghana.

By the final year of the PSMP project, LLINs with add-on features (such as zippers for easy entry, pockets, easy hanging mechanisms) had replaced standard LLINs as the main design purchased through retail outlets. It was assumed that this change in consumer demand would continue for the 5 years post-project with an average retail price of USD 7.48 (based on results of the human centred design study on LLIN preferences [28] and willingness to pay amongst middle-class households in the project area [27]). To model the financial contributions by households via LLIN purchase, assumptions about the number of households buying LLINs were made drawing on PSMP monitoring data on retail sales, and willingness to pay probabilities and least poor population estimates from the discrete choice experiment by Alonso et al. [27].

Estimates for domestic resource mobilization 5 years post-project were informed by the plans and targets described in the Resource Mobilization Strategy for National Malaria Control and Elimination (2019–23) [32]. The strategy rates potential resource mobilization measures for applicability and feasibility; to project the catalysing effect of PSMP, the costs of the measures rated in the strategy as “most feasible” for the public and private sector were estimated. Over the timeframe for this analysis, the most feasible source of increased public spending on malaria was rated to be activating the 0.5% of District Assembly Common Funds (DACF) ear-marked for local-level malaria control activities (0.5% of the 2018 DACF budget nationally came to USD 1,757,661) [32]. The Resource Mobilization Strategy assessed the most feasible potential sources of private investment in the near-term to be match funding programmes where every USD 1 of private donation would be matched by USD 1 from international donors or foundations [33], corporate fundraising (e.g. a recent telethon led by Ecobank Ghana), and investments by philanthropists and diaspora [32]. These various private investments would be coordinated by the Ghana Malaria Foundation using a public–private partnership model, whereby funds will be used in alignment with the national malaria strategic plan via a Technical Oversight Committee chaired by the NMCP.

Analysis

Costs were collected in the currency of expenditure. Costs in GHS were adjusted for inflation to 2019 GHS using consumer price indices available from the International Monetary Fund [34] and then converted to 2019 USD using the official average annual exchange rate for 2019 (1 USD equivalent to GHS 5.03 [35]) [31]. Costs in USD were adjusted for inflation and are presented as 2019 USD using consumer price indices available from the International Monetary Fund [34]. Capital goods with an expected lifespan of more than 1 year were annualized using a discount rate of 3% [36]. A useful lifespan of 8 years was used for vehicles and office equipment, and 10 years for furniture [37].

Cost per LLIN distributed during the project

The number of LLINs delivered through retail and workplace partners during the 3 years of the project was reported by PSMP annually, based on data collected on a routine basis from the project’s partners:

  • LLIN distributors reported on the number of LLINs sold to retail outlets

  • LLIN distributors and institutional partners reported on the number of LLINs distributed through Malaria Safe workplace initiatives; numbers from these two sources were triangulated to avoid double-counting

Estimates of numbers of LLINs sold to retail outlets and distributed by workplace partners in the year prior to PSMP were also obtained. It was assumed that without the catalytic activities of PSMP, the annual volumes of LLINs sold through retail outlets would have remained constant, so pre-PSMP volumes were subtracted from annual intervention-period volumes to calculate the incremental number of LLINs delivered through retail outlets due to the PSMP project. For the workplace partners, information on pre-project LLIN distributions was obtained via baseline questionnaires with the partners: 47 of 50 workplace partners completed the questionnaire, of these only 4/47 reported that they had previously purchased nets. As the majority of workplace partners were distributing LLINs for the first time, it was assumed that all LLINs purchased through PSMP were due to the project activities.

Total financial costs to the donor of supporting the retail sector or workplace partners were divided by the incremental number of LLINs distributed to retail outlets or workplace partners during the 3 years of project implementation to estimate the donor’s financial cost per LLIN delivered through each of these respective channels.

To estimate average annual economic cost over the effective lifespan of the LLINs delivered through the retail sector or workplace partners, project costs supporting these activities were annualized across the average LLIN retention time in Ghana of 1.78 years [38] using a discount rate of 3% [37]. This reflects that the donor-supported costs are investments expected to last as long as the LLINs.

Predicted expenditure catalysed by the donor investment in the 5 years post-project

The activities and outcomes of the project were broader than those reflected through cost per net distributed during the lifespan of the project, reflecting its goal to catalyse private sector investment in malaria control. The intermediate consequences of the donor investment in PSMP-supported activities were brought together by calculating annual ratios of non-donor expenditure to donor expenditure for the 5 years after project end.

To calculate annual donor investment costs, the donor-funded costs of the PMSP intervention were treated as investment (capital) costs and annualized using a discount factor of 3% across the lifespan of the intervention, adjusted for the year in which the cost was incurred. For example, costs incurred in year one of the project were divided by 7.02 (8 years discounted at 3%) reflecting that the effects of these activities would last for three years of project implementation plus 5 years post-project. Costs incurred in years two and three of the project were divided by 6.23 and 5.42, respectively (reflecting discounted lifespan of these activities of 7 and 6 years, respectively).

Five scenarios were created for the consequences of the PSMP intervention in terms of annual recurrent expenditure by all stakeholders (donor, public, private and households) for the 5 years after project implementation ended. The assumptions behind the five scenarios ranged from optimistic but feasible increases in non-donor expenditure in the best case to no change in the status quo in the worst case, as summarized in Table 2. The full list of annual recurrent costs to different stakeholders for the 5 years post-project are provided in Additional File 1, along with the estimated values for each scenario, and the data sources and assumptions.

Table 2 Overview of scenarios and assumptions for projections of expenditure in years one to five post-project

The catalysed expenditure analysis was drawn together to produce an annual ratio of non-donor expenditure to donor expenditure using the following simple formula for each year post-project:

Non-donor: donor expenditure ratio = (annual recurrent expenditure by households + public sector + private investors)/(annualized donor investment cost + annual recurrent donor expenditure).

A ratio greater than one indicates that the PSMP project catalysed greater public and private investment in malaria prevention than the donor investment. Conversely, a ratio less than one indicates that donor investment costs exceeded catalysed expenditure.

Sensitivity analysis

To investigate the effect of assumptions made on the annual non-donor to donor expenditure ratios, each was varied in one-way sensitivity analyses. The base case discount rate of 3% used to annualize donor investment costs was varied to 0% and 5% [31]. The proportion of households willing to purchase an LLIN with add-on features, and price per LLIN with add-on features that these households were willing to pay were varied by ± 25% of the base case parameter value [27].

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