GHANA
NetMark was active in Ghana between November 2002 and September 2009,implementing activities in seven out of the ten regions in Ghana.
USAID Country Project Budget: $7,183,000
Commercial Partners’ Investment: $13,025,647
NETMARK PARTNERS
| Agrimat (GH) Ltd | Dawa™ |
| Transcol West Africa Ltd | Dawa PLUS ® |
| NetCo Rockville (GH) Ltd | K-O ®Tab 123 (a long-lasting retreatment kit) |
| Health Commodities Ltd | PermaNet® |
| Enkark Ventures Ltd | PermaNet® |
| Reiss & Co (GH) Ltd | PermaNet® |
| Integrated Netting (GH) Ltd | PermaNet® |
| K-O® Tab (a treatment kit) | icoNet®, IconLife® |
| K-O® Net (a bundled net) | Olyset® Net |
ENABLING ENVIRONMENT
A parliamentary act in 2001 removed taxes and tariffs (T&T), including value added tax (VAT), on insecticide-treated nets (ITNs). However, private sector importers still paid T&T when NetMark was launched in Ghana in 2002, because exemptions were not being applied at the ports of entry. NetMark worked with the Customs, Excise and Preventive Service and VAT Commission to support enforcement of T&T exemptions.
During the project period, NetMark created demand for ITNs by airing radio and television ads based on formative research; made ITNs available to vulnerable groups at subsidized prices through voucher schemes; and provided technical support to the private sector to create effective marketing and distribution systems. In 2006, The Global Fund provided funds for the Ghana Ministry of Health and the Ghana Health Service to distribute ITNs at no cost or reduced cost to families. Free ITN distributions took place nationwide during integrated child health campaigns in November of 2006, 2007, and 2008. The World Bank has distributed ITNs free to families in Ashanti Region. The following table summarizes ITN promotion activities in the study sites where baseline and endline surveys took place.
ITN Promotion Activities in the Study Sites
ANC=antenatalcare
GHS = Ghana Health Service
GFATM = Global Fund for AIDS, Tuberculosis, and Malaria
MOH = Ministry of Health
SUPPLY OF ITNs
Brands and Sales:
Two distributors were selling small volumes of ITNs, primarily to NGOs, in 2002. By 2009 four LLIN brands were registered in the country and widely available in the market. The number of styles and shapes available in the commercial market also increased. In 2002 only polyester nets were available; polyester and polyethylene LLINs in different shapes, sizes, and colors were available in 2009.
Retail Outlets/Accessibility:
The number of retail outlets in the country selling ITNs grew from 30 at the start of the project in 2002, to approximately 3,600 by NetMark’s final year in 2009.
Price:
As a result of both increased competition and removal of taxes and tariffs, a consumer who paid $7.14 for an untreated net in 2001 could buy an LLIN for $6.45 in 2009.
EQUITY – VOUCHER PROGRAM AND FREE NETS
Vouchers:
NetMark-Ghana employed the market priming effect of the commercial discount-voucher scheme to create ITN demand in the communities and among retailers, to extend ITN distribution to rural communities, and to enhance access to ITNs among vulnerable populations. Following a successful pilot of discount vouchers in the Volta region, the program was successfully expanded to six out of the ten regions in Ghana.
A total of 1,041,076 ITNs have been purchased by pregnant women and mothers of children under five using discount vouchers through commercial retail outlets. The average redemption rate has been 87%.
Through the voucher scheme, NetMark leveraged a total of USD $900,000 additional resources from other donors, including ExxonMobil and DfID. The voucher scheme was successfully extended to the community level to reach the vulnerable groups that would not be reached through the routine health- facility-based antenatal and child welfare services.
Free Nets Distribution:
In Ghana, NetMark offered technical assistance and supported the successful design and implementation of the national integrated measles campaigns. NetMark support included design of the logistics system, training of volunteers, and printing of vouchers.
The total subsidized sales is made up of 330,869 ITNs funded by USAID/PMI in the Central Region, 537,600 ITNs for the Global Fund-funded scheme in Ashanti, Brong Ahafo, Eastern, and Volta Regions, 72,292 funded by DfID for the pilot in the Volta and Eastern Regions, and 100,315 funded by ExxonMobil in the Greater Accra and Ashanti Regions. NetMark provided technical assistance to the National Malaria Control Program for the successful implementation of all the GFTAM-supported voucher schemes. 
HOUSEHOLD OWNERSHIP AND USE
Ownership of Nets and ITNs:
NetMark conducted household surveys inGhanain 2004 and 2008. (The intended baseline was done by another group in2001 but had too many data errors to be useful.) The 2008 ssample consisted of 1796 women of reproductive age (15-49) who were pregnant or caring for a child under five, from six regions: Accra and Eastern, Ashanti, Central, Volta, Northern, and Upper West. Both urban and rural areas were included. The surveys measured change over time – due to NetMark and others, although NetMark activities and the Global Fund that provided nets free to households were the major inputs to ITN promotion during this period.
In 2004, 91% of women surveyed had heard
of treated nets, and by 2008,awareness of treated nets was nearly universal. Household ownership of nets increased dramatically during the 
NetMark years. Ownership of at least one net increased from 29% to 71% between 2004 and 2008. The percent of netsowned that were ITNs (including LLINs) jumped from 31% in 2004 to 86% in 2008.
Ownership of ITNs in Ghana is highly equitable,with no more than a ten-point difference among socio-economic quintiles. In 2004, net and ITN ownership varied widely across regions, but in 2008 it was also more evenly distributed geographically.
Use by Vulnerable Groups:
Children under five and pregnant women were the household members most likely to sleep under a family net. Between 2004 and 2008, use of ITNs specifically by both of these groups increased approximately five-fold. Net use by both children and pregnant women was higher in rural than in urban areas. 
Overall Household Use:
Families that owned nets began using them for longer periods in the year: the average number of months nets were used rose from 7.8 to 9.3. The percent that used their nets year-round rose from 41% to 58%. (Nets should be used even when there are few mosquitoes; malaria can be transmitted by a single bite.)
On a less positive note, a larger percent of nets owned went unused. Three out of four nets had been used the prior night in 2004, but as net ownership increased, the percent of nets used decreased to 59% in 2008. Nets that were acquired free of charge were used less (55%) than nets that had been paid for (68%).
CONCLUSIONS
The “net picture” changed dramatically for the better in Ghana between 2004 and 2008. Awareness of ITNs has become universal and the majority of households now own at least one net – almost all of them ITNs, including LLINs. Ownership of ITNs is evenly distributed among socioeconomic groups. The soaring increase in ITN ownership during these years reflects the success of demand creation and the “mixed model”: a segmented market in which free, subsidized, and commercial nets are made available.
Furthermore, within net-owning households, children under five and pregnant women are given priority for use of the net, and most families use their nets year-round. ITNs have become much more favorably regarded than other insect-control products. Few people perceive any disadvantages of using ITNs.
