WHO Mosquito Net

8/9/2019 WHO Mosquito Net

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World Health Organization

Insecticide-treatedmosquito net

interventions

A manual fornational controlprogramme managers

E d i t e d b y R O LL B A CK M A L AR I A


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World Health OrganizationGeneva, 2003

Insecticide-treatedmosquito net

interventions

A manual fornational controlprogramme managers

E d i t e d b y R O LL B A CK M A LA R IA

WHO/CDS/RBM/2002.45


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ROLL BACK MALARIA is a global partnership founded by the governments ofmalaria-afflicted countries, the World Health Organization, the UN ChildrensFund, the World Bank and the UN Development Programme. Its objective is tohalve the burden of malaria for the worlds people by the year 2010 by savinglives, reducing poverty, boosting school attendance and making life better formillions of people living in poor countries, especially in Africa.

ROLL BACK MALARIAWorld Health Organization 20, avenue AppiaCH-1211 Geneva, 27 Switzerland

Fax: (+41) 22 791 48 24E-mail: [email protected] site: http://www.rbm.who.int/

World Health Organization, 2003

This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization.The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but not for sale or foruse with commercial purposes.

The views expressed by named authors are solely the responsibility of those authors.

The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommendedby WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietaryproducts are distinguished by initial capital letters.

Further information at: CDS Information Resource Centre, World Health Organization

CH1211 Geneva 27 Fax: +(41) 22 791 4285 E-mail: [email protected]

Quality control: Communications team of the WHO Programme on Communicable diseasesDesigned by: Bruno Duretii

WORLD BANKWorld HealthOrganization

WHO Library Cataloguing-in-Publication Data

Insecticide-treated mosquito net interventions : a manual for national control programme managers / edited by Roll Back Malaria.

1. Malaria prevention and control 2. Mosquito control methods 3. Bedding and linens 4. Marketing of health services5. Manuals I.Global Partnership to Roll Back Malaria.

ISBN 92 4 159045 9 (NLM Classification : WC 765)


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List of tables and figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

List of abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii

CHAPTER 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

1.1 Implementation experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.1.1 Nets before ITNs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

41.1.2 Efficacy and effectiveness trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1.1.3 Early ITN projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.1.4 Moving from projects to programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.2 Developing national ITN strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1.2.1 Bringing partners together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

1.2.2 Assessing the capacity of the commercial sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1.2.3 Creating an enabling environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

1.2.4 Establishing partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

1.3 Potential approaches to ITN interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.3.1 Demand creation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

1.3.2 Sustained subsidies for equity (targeting vulnerable groups) . . . . . . . . . . . . . . . . . . . . . . . . 16

1.3.3 Revolving fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.3.4 Social marketing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1.3.5 Pump-priming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.3.6 Emergency relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

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CHAPTER 2 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

2.1 Institutional and policy factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

2.1.1 Organizational mandate and scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

2.1.2 International and national context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

2.1.3 Other organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

2.1.4 The commercial market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

2.2 Malaria epidemiology and population factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

2.2.1 Malaria epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

2.2.2 Vector species and biology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272.2.3 Demographic data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

2.2.4 Vulnerable groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

2.3 Net and insecticide factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

2.3.1 Net and insecticide distribution and use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

2.3.2 Net preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

2.3.3 Ability and willingness to pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

2.4 Knowledge and attitude factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

2.4.1 Perceptions about malaria, its causes and prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

2.4.2 Perceptions about nets, insecticides and ITNs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382.4.3 Sources of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

CHAPTER 3 Planning, monitoring, and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

3.1 Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

3.1.1 Developing a national strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

3.1.2 Developing a framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

3.1.3 Staffing, training, and supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

3.1.4 Budgeting and funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

3.1.5 Planning monitoring and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

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3.2 Monitoring and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

3.2.1 Indicators for monitoring and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

3.2.2 Methods for measuring indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

CHAPTER 4 Sourcing and procurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

4.1 Nets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

4.1.1 Types of nets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

4.1.2 Quantity of nets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

4.1.3 Sources of nets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

4.2 Insecticides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

4.2.1 Type of insecticide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

4.2.2 Insecticide formulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

4.2.3 Packaging and labelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

4.2.4 Quantity of insecticide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

4.2.5 Sources of insecticide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

4.2.6 Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

4.2.7 Efficacy monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

4.3 Ordering systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

CHAPTER 5 Financing and distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

5.1 Financing options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

5.1.1 No-cost recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

5.1.2 Partial-cost recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

5.1.3 Full-cost recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82

5.2 Pricing policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

5.3 Distribution and delivery options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

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CHAPTER 6 Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91

6.1 Define promotion objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

6.2 Plan implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

6.2.1 Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

6.2.2 Implementing agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

6.2.3 Target audience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

6.2.4 Timing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

6.3 Develop messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

6.4 Identify communication channels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98

6.5 Pre-test, post-test and evaluate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

CHAPTER 7 Social marketing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

7.1 What is social marketing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105

7.2 Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

7.3 Product . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

7.3.1 Nets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

7.3.2 Insecticide treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1087.3.3 Branding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

7.3.4 Market segmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

7.4 Price . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

7.4.1 Pricing structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

7.4.2 Cost recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

7.4.3 Subsidies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

7.5 Place . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

7.5.1 Distribution channels and outlets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112

7.6 Promotion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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List of tables and figures

Tables

1.1 Impact of ITNs on overall mortality, mild malaria disease, parasitaemiaand anaemia, measured under programme conditions

1.2 Potential approaches to ITN interventions

2.1 Characteristics of Anophelesvectors in Africa and Asia

2.2 Sources of information

2.3 Perceptions that may enable or block the introduction of ITNs

3.1 Potential roles and responsibilities of different partners

3.2 Framework for a monitoring and evaluation plan

3.3 Impact indicators3.4 Purpose indicators

3.5 Output indicators

3.6 Data collection tools for impact indicators

3.7 Example of a logical framework for a social marketing strategy

4.1 Insecticides recommended for net treatment

4.2 Advantages and disadvantages of different approaches to ordering

5.1 Financing options

5.2 Selecting the most appropriate financing option

5.3 Selecting the most appropriate pricing policy

5.4 Distribution of nets and insecticides

5.5 Delivery of nets

5.6 Delivery of insecticides for net treatment

6.1 Using assessment of current KAP to develop promotion objectives


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Figures

1 Overview of planning ITN interventions

2 The relationship between ITNs and malaria mortality: the example of Viet Nam

3 The repellent effect of the insecticide deters mosquitoes from entering the room. A treatednet provides protection to the people sleeping under it, even if it is torn or not tucked incompletely. The insecticide provides some protection to those not sleeping under a net

4 Roles of the public sector, NGOs and the commercial sector in creating an enablingenvironment

5 The balance between equity and sustainability

6 Many factors have to be assessed when deciding whether a treated net project is feasible7 Making a simple map can help in assessing areas of high malaria transmission

8 It is important to assess community interest in treated nets and to secure communitycommitment

9 Developing a project framework, comprising purpose, outputs and activities

10 A sample tool for monitoring net coverage. Measuring household coverage of ITNs is animportant indicator in Roll Back Malaria

11 Focus group discussions can help to assess changes in perceptions about nets

12 Nets are available in a number of different shapes and sizes

13 Washing nets in a bucket or bowl rather than a stream prevents insecticides contaminatingwater sources. Wring the net gently. Gloves should be worn when washing or treating nets

14 Nets can be provided at no-charge or at low prices to target vulnerable groups, such aschildren under five and pregnant women

15 Barriers to behavioural change

16 Drama or role play, the radio, and personal communication are all methods that can be usedto promote ITNs

17 It is important to pre-test promotional materials with a smaller group before using them withthe wider community

18 Understanding the target audience is a vital part of social marketing

19 Sales agents that travel to communities can make nets more accessible

List of tables and figures


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AFRO WHO Regional Office for AfricaBASICS Basic Support for Institutionalizing Child SurvivalCS Capsule suspension [insecticide formulation]DANIDA Danish International Development AssistanceDFID Department for International Development (United Kingdom)DHS Demographic health surveyDIY Dip-it-yourself [insecticide kit]DSS Demographic surveillance systemEC Emulsifiable concentrate [insecticide formulation]EW Emulsion oil in water [insecticide formulation]

HIS Health information systemIDP Internally displaced personsITN Insecticide-treated mosquito netKAP Knowledge, attitude and practice [survey]MARA Mapping Malaria Risk in AfricaMCH Mother and child health [clinic]MoH Ministry of HealthNGO Nongovernmental organizationNMCP National malaria control programmePATH Programme for Appropriate Technology in Health (Canada)PCV Packed cell volume

PSI Population Services InternationalRBM Roll Back MalariaSC Suspension concentrate [insecticide formulation]UNHCR Office of the United Nations High Commissioner for RefugeesUNICEF United Nations Childrens FundUSAID United States Agency for International DevelopmentWT Water dispersible tablets [insecticide formulation]WHO World Health OrganizationWHOPES WHO Pesticide Evaluation Scheme

List of abbreviations


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There can be no doubt about the effectiveness of insecticide-treated mosquito nets (ITNs). The resultsof studies completed in 2000 and 2001 confirm and supplement the findings of the major studies ofthe 1990s to evaluate the impact of ITNs. The widespread use of ITNs can be expected to reduce all-cause child mortality in malaria endemic areas by about 20%. ITNs must therefore rank on a par withimmunisation against common childhood diseases and oral rehydration therapy as a revolutionaryintervention that has the potential to dramatically improve child health and contribute to overalldevelopment.

However, in contrast to childhood immunisation where even the poorest countries are able todemonstrate sustainable coverage rates of 70% or more, in spite of the difficulties posed by the need

for a cold chain and specially trained staff to administer injections very few countries have morethan 20% of children at risk from malaria sleeping under ITNs. Net coverage is increasing, but if theambitious goal of having 60% of the at-risk population sleeping under ITNs by 2005 agreed to at theAbuja Summit of 2000 is to be achieved, very signficant efforts need to be made to accelerate theintroduction and use of insecticide-treated nets.

This manual attempts to gather together much of the available information, based on the experienceof the last 15 years, which is necessary to develop, expand and monitor ITN programmes. It is hopedthat the manual will serve as a guide and reference to programme managers in countries, at nationaland at sub-national level, as well as a resource to workers in civil society organizations and the privatesector who will be pivotal in achieving high coverage rates of effectively-treated mosquito nets.

There are several current factors that could help to significantly increase the effective use of treatednets in malaria endemic countries. Firstly, as demand for mosquito nets and insecticides increases,prices are falling. Whereas five years ago it was difficult to find a net for less than the equivalentof US$ 10 anywhere, in many malaria-endemic countries today they can now be purchased byindividual families for US$ 5, and in some countries for as little as US$ 3. This reduction is partly dueto increased demand and competition, and partly due to the success of global efforts to eliminatetaxes and tariffs on nets, netting and insecticides. With an effective life of five years, this makes anITN a highly cost-effective health investment, no matter who pays.

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Secondly, data released and reviewed by an expert committee at the end of 2001 confirm that thetechnology now exists to produce a mosquito net which is treated with insecticide at manufactureand which will retain its effective mosquito repelling properties for at least four years. The need toperiodically re-treat conventional nets by dipping them in insecticide is widely agreed to be a majorimpediment in implementing effective and sustainable programmes.

Thirdly, the Global Fund to Fight Aids, TB and Malaria has been launched. This fund is expectedto help the most needy countries implement effective plans to combat these diseases. It is anticipatedthat proposals for scaling up the use of ITNs from countries where malaria is a major contributorto child mortality will be well received by the fund. The fund managers will probably be looking for

signs of synergy in efforts to tackle the three diseases, so malaria planners would be wise to seekout their counterparts working in AIDS and TB to discuss how efforts to distribute and promote ITNsmight be linked with the promotion and distribution of condoms, or with strategies such as DOTSfor TB.

Roll Back Malaria genuinely solicits feedback from readers and users which will be used to planfuture editions of this work.

David Alnwick

Roll Back Malaria

WHO HQ GenevaDecember 2002

Preface


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This manual was written for Roll Back Malaria (RBM) by Jayne Webster, Jo Lines and Jenny Hill,of the Malaria Consortium, a collaborative project of the Liverpool School of Tropical Medicineand London School of Hygiene and Tropical Medicine. The Malaria Consortium is supportedfinancially by the United Kingdom's Department for International Development (DFID), to whomwe give our thanks.

Contributors include A. T. Aitio, K. Attawell, B. Ayaneshewa, C. Baume, N. Besbelli, D. Chavasse, R. Cole,M. Ejov, E. Feller-Dansokho, P. Guillet, S. Lindsay, L. Manga, K. Reed, M. Renshaw, J. Rowley, and M. Zaim.

The illustrations are taken or adapted from other relevant malaria publications: Insecticide-treated

net projects: a handbook for managers(Malaria Consortium, 1999), Partnerships for change andcommunication: guidelines for malaria control(WHO/Malaria Consortium, 1997).

Thanks to June Mehra for permission to reproduce illustrations from Partnerships for change, andfor new illustrations produced for this manual. Thanks also to Michel Lavigne for the illustrationsfrom the Insecticide-treated net projectshandbook.

Acknowledgements


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Introduction

Chapter 1


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2

This manual provides guidance on

approaches to insecticide-treated

mosquito net (ITN) interventions.

It is intended mainly for national

malaria control programme

(NMCP) managers, but it could also

be used by nongovernmental

organizations (NGOs) and the

private sector.

This manual does not attempt to dealwith practical aspects of mosquito nettreatment (simplified guidelines are

currently being prepared by the WorldHealth Organization (WHO). It is intendedrather to provide NMCP managers withpractical how to guidelines to help themto develop:

national ITN going to scale strategies;

a long-term vision, with short-term

programmes contributing towards this

vision;

partnerships, with partners contributing

their specific areas of skill and expertise.

Each chapter covers a different aspect

of ITN interventions: Chapter 2 Assessment

Chapter 3 Planning, monitoringand evaluation

Chapter 4 Sourcing and procurement

Chapter 5 Financing and distribution

Chapter 6 Promotion

Chapter 7 Social marketing

Introduction

n


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Introduction

Figure 1 provides an overview of planningITN interventions and illustrates how thesechapters fit together.

This introductory chapter provides anoverview of ITN implementation experience,of key aspects of developing national ITNstrategies, and of the range of potentialapproaches to ITN interventions.

Figure 1. Overview of planning ITN interventions

ASSESSMENTChapter 2

SOURCING ANDPROCUREMENT

Chapter 4

PROMOTIONChapter 6

FINANCING AND

DISTRIBUTIONChapter 5

PLANNING, MONITORING

AND EVALUATIONChapter 3

FURTHERASSESSMENT

INITIALASSESSMENT

Determinefinancing for nets

and insecticide

Determinefinancing for

other components

Define pricingpolicy for netsand insecticide

Plan distributionmechanisms for

nets and insecticide

Plan outlets fornets and insecticide

Develop a projectframework with

indicators

Gather/developtools and samplingscheme for M & E

Develop timeframefor M & E

Define roles andresponsibilities

Develop frameworkfor feedback

Determine thepreferred nets and

insecticide

Determine number ofnets and amount ofinsecticide needed

Determine where tosource nets and

insecticide

Design theprocurement system

Formativeresearch

Definecommunication

objectives

Develop messagesand determinecommunication

channels

Pre-test and modifystrategy

ADOPTA STRATEGY


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1.1 Implementation experience

Experience over the past 20 years hasshown ITNs to be a promising interventionfor reducing the risk of malaria infectionin areas of both stable and unstabletransmission. During this time, ITNimplementation has evolved. The mainphases, discussed in more detail below,have been:

private sector sales of untreated netsbefore the development of ITNs as a new

technology; ITN efficacy and effectiveness trials;

early ITN projects;

moving from projects to programmes(going to scale).

Many lessons have been learned from thisexperience, but there is still much to learn.This section highlights successes andconstraints and also discusses challenges

to going to scale, including financing andpricing, targeting vulnerable groups andpromotion.

1.1.1 Nets before ITNs

Before the development of ITNs as a newtechnology in the mid-1980s, people inmany countries were already using nets,mainly to protect themselves againstmosquito biting. There are limited dataabout household coverage with netsprior to the introduction of ITNs, but it isclear that the extent of net usage variedconsiderably. Pre-existing net usage wasvery high in some countries, such as theGambia, and very low in others, such asMozambique, with levels in most countriesfalling somewhere between these twoextremes.

1.1.2 Efficacy and effectiveness trials

The potential epidemiological advantagesand public health benefits of treating netswith insecticide for protection againstmalaria were recognized in the mid-1980s.

Efficacy is measured as impact under controlledtrial, i.e. almost ideal, conditions.

Effectiveness is measured as impact underprogramme, rather than trial, conditions.

on


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Introductio

To evaluate the potential of ITNs, efficacytrials were carried out in countries with a

wide range of transmission intensities inAfrica, Asia, Latin America and the WesternPacific. The majority of these trials wererandomized-controlled trials, comparingITN use with no-net use and, less commonly,comparing ITN use with use of untreatednets. The impacts measured have includedall-cause child mortality (age 159 months),incidence of severe malaria, incidence ofuncomplicated malaria episodes, prevalence

of parasitaemia, mean haemoglobin level,splenomegaly, and nutritional status.

A Cochrane review1 concluded that ITNsreduce overall mortality by about 20% inAfrica (range 1429%2, 3, 4, 5) and that, forevery 1 000 children aged 159 monthsprotected by ITNs, about six lives are savedeach year. The review also concluded thatITNs reduce clinical episodes of uncom-plicated malaria caused by Plasmodium

falciparum and Plasmodium vivaxinfections by 50%, as well as reducingparasitaemia. The impact on anaemiastatus, measured as increases in PackedCell Volume (PCV), is variable.

Having established the efficacy of ITNsunder trial conditions, effectiveness trialswere conducted to evaluate impact underprogramme conditions.

1 Lengeler C. Insecticide-treated bednets and curtains for malaria control (Cochrane Review).In: The Cochrane Library. Oxford: Update Software, 1998:3.

2 Habluetzel A et al. Do insecticide-impregnated curtains reduce all-cause child mortality in Burkina Faso?Tropical Medicine and International Health, 1997, 2(9):85562.

3 Binka F et al. Impact of permethrin inpregnated bednets on child mortality in Kassena-Nankana district,Ghana: a randomised controlled trial. Tropical Medicine and International Health, 1996, 1(2):14754.

4 DAlessandro U et al. Mortality and morbidity from malaria in Gambian children after introduction of animpregnated bednet programme. Lancet, 1995, 345:47983.

5 Nevill C et al. Insecticide-treated bednets reduce mortality and severe morbidity from malaria amongchildren on the Kenyan coast. Tropical Medicine and International Health, 1996, 1(2):13946.

14 000

12 000

10 000

8 000

6 000

4 000

2 000

0

90 91 92 93 94 95 96 97

5 000

4 000

3 000

2 000

1 000

0

Figure 2 The relationship between ITNs and malaria mortality:

the example of Viet Nam

Population protected by insecticide

and malaria deaths from 1990 to 1997 in Vietnam

Indoor residual spraying (IRS) IRS + ITNS Deaths


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6 Impact under operational conditions.7 DAlessandro U et al. Mortality and morbidity from malaria in Gambian children

after introduction of an impregnated bednet programme. Lancet, 1995,345:47983.

8 Matched with health centre controls.9 Matched with village controls.10 DAlessandro U et al. The Gambian National Impregnated Bed Net Programme:

evaluation of effectiveness by means of case-control studies. Transactions ofthe Royal Society of Tropical Medicine and Hygiene, 1997, 91:638642.

11 Plasmodium falciparum.12 Plasmodium vivax.

13 Rowland M et al. Sustainability of pyrethroid-impregnated bednets for malariacontrol in Afghan communities. Bulletin of the World Health Organization, 1997,75(1):239.

14 Abdulla S et al. Impact on malaria morbidity of a programme supplying

insecticide-treated nets in children aged under 2 years in Tanzania: communitycross sectional study. British Medical Journal, 2001, 322:270273.

15 Reduction in post-neonatal child death. Combined with coverage data, thissuggests that ITNs prevented 1 in 20 post-neonatal child deaths. If the effect ofuntreated nets is taken into account, then this increases to 1 in 10 post-neonatalchild deaths prevented.

16 Armstrong Schellenberg J et al. Effect of large-scale social marketing ofinsecticide-treated nets on child survival in rural Tanzania. Lancet, 2001,357(21):12411247.

Table 1.1 Impact of ITNs on overall mortality, mild malaria disease, parasitaemia and anaemia, measured under programme conditions

Country Study Impact (protective efficiency6

) SourceOverall mortality Mild disease Parasitaemia Anaemia

(fever andparasitaemia)

Gambia Longitudinal 2540% DAlessandrosurveillance et al. (1995)7

Gambia Case control 0% 59%8 DAlessandrostudy 0%9 et al. (1997)10

Pakistan Case control 78%11 Rowland et al.study 69%12 (1997)13

United Republic Cross sectional 62% 63% Abdulla et al.of Tanzania survey (2001)14

United Republic Case control 27%15 Armstrongof Tanzania study Schellenburg

et al. (2001)16

ion


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7

Introducti

Measuring effectiveness is more difficult andmethods used have included population-based

active surveillance, health-service-basedpassive surveillance, repeated cross-sectionalsurveys, and case control studies. Althoughthe results have been varied (see Table 1.1),due in part to different methodologies andchoices of control groups, these trials haveprovided good evidence of the effectivenessof ITNs.

1.1.3 Early ITN projects

ITN projects have been implemented in manycountries since the 1980s. These projects, andthe degree to which they have been successful,have varied in ways that include:

rationale for the geographical area ofimplementation (e.g. organizationalmandate, historical presence);

transmission intensities and vectors inthe implementation area;

indicators for monitoring and evaluation; target group or population;

type and variety of nets and insecticidesupplied;

distribution mechanism for nets and/orinsecticide;

outlet for delivery of nets and/or insecticide;

pricing policy for nets and insecticide;

methods used to promote ITNs;

Source: Chavasse D, Reed C, Attawell K. Insecticide-treated net projects: a handbook for managers. MalariaConsortium, 1999.

Figure 3. The repellent effect of the insecticide deters mosquitoes from enteringthe room (1). A treated net provides protection to the people sleeping

under it, even if the net is torn or not tucked in completely (2). Theinsecticide provides some protection to those not sleeping under a net (3)


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number and quality of partnershipsbetween organizations.

Only a few countries, such as China, theGambia, Solomon Islands and Viet Nam,have implemented ITN interventions on anational scale. China and Viet Nam havefocused on treating existing nets ratherthan distributing nets, and have achievedrelatively high rates of re-treatment. Thepopulation is responsible for acquiringnets, and the public sector is responsiblefor treating nets, either at no charge or athighly subsidized prices. The Gambia hasalso focused on re-treatment, given highlevels of pre-existing net usage.

Re-treatment rates were high initially whenthe service was provided at no charge, butfell dramatically when fees for re-treatmentwere introduced.

Most ITN projects, however, have beensmall scale, focusing on a few villages or

districts and involving limited collaborationwith other organizations or sectors. Small-scale projects have often succeeded inimproving coverage with nets andinsecticide in project areas, but theseprojects only cover a small proportionof the total population at risk of malaria.As a result, access to ITNs is still lowin most malaria-endemic countries.

1.1.4 Moving from projects

to programmes

Since the launch of the Roll Back Malaria(RBM) global partnership in 1998, therehas been increasing recognition of theneed to go to scale from small projectsto programmes that can achieve nationalcoverage with ITNs. There are an estimated500 million people at risk of malaria inAfrica alone. Approximately 250 millionnets are required to cover this populationand, if a net has an average life span of fiveyears, this means 50 million nets a year areneeded to maintain coverage.

Challenges to going to scale include findingthe most appropriate way to cover thecosts of increasing ITN coverage, while atthe same time ensuring that the poorestand most vulnerable are protected (seesection 1.3) and that the growth of thecommercial market is not undermined (seesection 1.2.2).

Cost is a major limiting factor to going toscale. Most malaria-endemic countries inAfrica spend only US$ 4 per capita a yearon health, equivalent to the average costof an untreated net in countries where netsare widely available. It would requireUS$ 200 million a year to provide 50 millionnets and a further US$ 25 million a year

tion


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9

Introduct

to treat these nets with insecticide. Thisis too costly for users alone or donors

(or governments). There are variouspossible approaches to cost sharing:

Both donor and user contribute to eachITN. Providing marginal subsidies for allITNs is easy to implement. However, thisapproach subsidizes those who can affordto pay the full cost of a net and may stillexclude the poorest.

Donors pay the whole cost of some ITNs

and users pay the whole cost of others.Targeting subsidies is less easy toimplement. It must be strictly controlledto prevent leakage to the non-targetpopulation and the development ofan illegal market in no-charge nets.

Donors contribute to ITNs for some targetgroups. Market segmentation is anapproach employed by many socialmarketing programmes, where nets ofdifferent prices are targeted at differentsocioeconomic groups. Branding is used totarget expensive nets at wealthier groupsand the profit from these nets is used tocross-subsidize lower priced nets forpoorer groups.

Users pay for nets and donors pay forinsecticides, or vice versa. This is the

approach used in China, the Gambia andViet Nam. The population is responsible for

buying their own nets, but the public sectorprovides subsidized re-treatment. This iseasy to implement, but the poorest may beexcluded from net ownership.

Chapter 5 provides more information onfinancing and pricing issues.

As mentioned above, there is limitedexperience with going to scale and nationalcoverage has only been achieved in a few

countries, mostly in Asia. As moreprogrammes attempt to go to scale withITN interventions, it will be important todocument the experience and, in particular,to identify difficulties encountered andeffective strategies to overcome thesedifficulties.


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1.2 Developing national ITNstrategies

Achieving large-scale coverage andovercoming the challenges of going toscale require the development of nationalITN strategies. Such strategies can developa long-term vision for ITNs and help toensure that all partners work together toachieve this vision. Some countries, suchas Ghana, Kenya, Mozambique and theUnited Republic of Tanzania, have already

developed national ITN strategies. Keysteps in developing a national ITN strategyinclude:

bringing together potential partners;

assessing the capacity of the commercialsector;

creating an enabling environment forITNs;

establishing partnerships.

1.2.1 Bringing partners together

One of the first steps in developing anational ITN strategy is to identify and bringtogether the partners that can contribute tothe development and implementation of thestrategy. It is important that these partners,representing the government, nongovern-mental and private sectors, work togetherto reach consensus on a shared vision for

the future of ITNs and that all activitiescarried out by partner organizations fit

within the national ITN strategy.

In many countries there have been manysmall-scale projects working in isolation.Some have achieved significant levels ofcoverage with nets, but few have sustainedthese achievements once project fundingand the supply of nets and insecticidesends. A national ITN strategy should aimto look beyond short-term approaches andbuild consensus on how best to achievesustainable supply and demand for netsand insecticides.

It is now generally accepted that sustain-ability will depend on nets, and possiblyalso insecticide, being distributed to themajority of the population through thecommercial sector, with the public sectorfocusing its resources on the most vulnerablegroups. Where consensus is reached that

this is the way forward for the nationalstrategy, partners need to agree on howbest to create an enabling environmentfor growth of the commercial sector andhow best to identify and target populationgroups unlikely to be reached by thecommercial sector. It is also importantto ensure that any current or planned ITNprogrammes implemented by the publicsector or NGOs do not undermine the

ction


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Introduc

growth of the commercial sector.If possible, such programmes should be

designed to complement and supportexpansion of the commercial market.

1.2.2 Assessing the capacity

of the commercial sector

The contribution of the private sector isoften underestimated. In many countries,the commercial market in nets has suppliedsubstantial numbers of nets. Data from anational survey in the Gambia in 199417, forexample, found that 5176% of householdsowned one or more nets, and a recentreview of available data18 found an average(mean) of 20% of households with one ormore non-project nets in 14 countries inAfrica, south of the Sahara.

Even in countries where it is assumed thatthere is no commercial market, nets may beavailable from retail outlets. The experienceof the United Republic of Tanzania showsthat a commercial market can develop veryrapidly, given the right conditions (see Box1). In countries where most people do notown nets, it is important to investigate netavailability in the commercial market and,if necessary, to catalyse sourcing (seeChapter 4) and distribution (see Chapter 5).Promotion (see Chapter 6) should onlybegin when nets are available.

Box 1 The growth of the commercial net market

in the United Republic of TanzaniaIn 1990 rates of household net coverage were moderatein some areas, such as Dar es Salaam, but low in otherareas. The status of the commercial market was similarto that of many other African countries.

In 1994 one factory began to make moderate qualitynets at moderate prices. Today three manufacturerstogether have the capacity to produce 4 million netsa year. Net sales in the retail sector increased from200 000 in 1994 to 1 000 000 in 1999 and, also in 1999,

500 000 nets were sold to NGOs.

Competition in the wholesale and retail markets hasboth improved the quality of nets and reduced prices.The market is now approaching saturation in someurban areas, with coverage at over 70%. This hasforced traders to seek new markets in rural areasresulting in significant increases in coverage.

17 DAlessandro U et al. Nationwide survey of bednets in rural Gambia. Bulletin of

the World Health Organization, 1994, 72(3):3914.18 Webster J et al. Review of household coverage of nets in non-project areas ofsub-Saharan Africa. Malaria Consortium, 2001.


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Unlike nets, the commercial market ininsecticides for net treatment is almost

non-existent. In many countries onlya small proportion of nets are treated,and almost all net treatment is carried outby government or NGO programmes orprojects. The availability of dip-it-yourself(DIY) insecticide kits for home treatmentof nets may lead to the development ofa commercial market, although the likelynature and size of this market has yetto be determined.

1.2.3 Creating an enabling environment

There is no standard definition ofan enabling environment nor are therespecific guidelines for creating an enablingenvironment. This is because the situationand the national strategy will be differentin each country, and the action requiredto create an enabling environment willdepend on the current status of the

commercial net and insecticide market.However, two important aspects of anenabling environment in every contextare taxes and tariffs, and demand creation.The role of the public sector, NGOs andthe private sector in creating an enablingenvironment for sustainable ITN coverageis illustrated in Figure 4.

Consumerinformation

Monitoring& evaluation

Behaviouralchange

Transitionalopening up

of markets:market priming Ensuring access forvulnerable groups

Local demand creation

Additional niche supply to specialtarget populations

(e.g. refugees)

Brand specificdemand creation

Distribution togeneral population

at commercialprice

Product development

Create enablingenvironment(e.g. taxes)

Research

Bring partners together

National genericdemand creation

Consumer protection& regulatory issues Demand

creation

NGOs

Public sector Commercialsector

Figure 4 Roles of the public sector, NGOs and the commercialsector in creating an enabling environment

Source: Adapted from an original diagram produced by part icipants involved in development ofthe Tanzanian national ITN strategy.

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Introdu

Reducing taxes and tariffs can catalyseprocurement, manufacture and distribution

of nets and insecticide, and supportexpansion of the commercial market. Thesereductions should apply to netting as wellas to ready-made nets, to enable localmanufacturers to compete. The need toreduce taxes and tariffs is now widelyaccepted and, at the African Summit onRoll Back Malaria in Abuja in April 2000,44 African Heads of States and Governmentspledged to: improve access to malaria

prevention through the reduction of taxesand tariffs for mosquito nets and materials,insecticides, anti-malarial drugs and otherrecommended goods and services that areneeded for malaria control strategies.

Creating demand for nets and insecticidewill also support expansion of the commercialmarket and catalyse competition within theprivate sector.

All partners should play a role in demand

creation, but in different ways. In countrieswhere national ITN strategies are beingplanned, it is envisaged that the publicsector and NGOs will play a key role ingeneric demand creation, leaving thecommercial sector to supply and distributenets and insecticide and to promotespecific branded products. Chapter 6provides more information about

promotion. The capacity of the privatesector, however, for both the manufacture

and distribution of nets and insecticidevaries considerably between countries andshould be assessed before consideringa strategy that depends upon capacityin this sector.

The effect of brand-specific advertising,used by some social marketingprogrammes, on the commercial marketis still not clearly understood. Mostexperience of branding of socially

marketed products is through condomprogrammes. Social marketing of condomshas provided evidence of the halo effect,where promotion of a specific brand alsoincreases sales of other brands. Theevidence for this halo effect on sales ofnets and insecticide, however, is stillinconclusive, because information aboutthe impact of ITN interventions onthe commercial net and insecticide market

is limited. More information is neededso that countries can make informeddecisions about national strategies.Chapter 7 provides more informationabout social marketing.


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1.2.4 Establishing partnerships

Some countries have established public-private partnerships, between NMCPs orother public sector institutions and thecommercial sector, to support going toscale with ITNs.

Ghana, for example, has included public-private partnerships in its national ITNstrategy. Useful lessons can be learnedfrom the Ghanaian experience of suchpartnerships (see Box 1.2).

Effective public-private partnershipsdepend on the partners having the samepurpose, such as increased net sales, evenif the reasons for the purpose are different.The reason for the purpose is likely to bedifferent for each partner: public goodin the public sector, and commercial profitin the commercial sector.

Box 1.2 : Public-private partnerships in Ghana

The NMCP opted for a public-private partnership to increasethe accessibility and affordability of ITNs in Ghana. An ITN taskforce was established including representatives from the Ministryof Health (MoH), United Nations Children's Fund (UNICEF),WHO, United States Agency for International Development(USAID), United Kingdom Department for InternationalDevelopment (DFID), Danish International DevelopmentAssistance (DANIDA), Programme for Appropriate Technologyin Health (PATH) Canada, Basic Support for InstitutionalizingChild Survival (BASICS), commercial firms and the Ghana

Social Marketing Foundation.The aim of this task force partnership is to create demand forITNs and re-treatment of nets, and for this demand to be metby the commercial sector. Challenges identified include:

increasing awareness of the advantages of using an ITN sothat people will be willing to pay the cost;

encouraging the government to waive taxes throughappreciation of the advantages of the population using ITNs;

expanding the governments health cost exemption policyfor under fives to include ITNs;

increasing the availability, and thereby bringing down thecosts, of nets (this is a particular challenge, since Ghana hasno local manufacturers of nets, importers need capital tocover their costs, and retailers want nets on credit fromimporters).

Source: Marfo C. Presentation at the workshop on the promotion ofinsecticide-treated nets in the Africa region. Harare, 69 March 2001.

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Introd

1.3 Potential approachesto ITN interventions

National strategies can employ one or moreof a range of potential approaches to ITNinterventions (summarized in Table 1.2),including:

demand creation;

sustained subsidies for equity;

revolving fund;

social marketing;

pump-priming; emergency relief.

The choice of approach or approacheswill depend on the national context and, inparticular, on the status of the commercialmarket, and on factors to do with institutionalpolicy, epidemiology and population,nets and insecticide, and knowledge andbehaviour. Chapter 2 provides informationabout assessment of these factors.

Different approaches may be requiredfor financing, distribution and promotionof nets and insecticide, because supplyof and demand for these commodities areoften very different. Chapter 5 providesmore information on financing anddistribution; and Chapter 6 more informationon promotion.

1.3.1 Demand creation

A demand creation approach aims tostimulate increased demand in orderto stimulate increased supply by thecommercial market. There is unlimitedscope for scaling up demand creation. Thepublic sector, NGOs and the private sectorall have a role to play in creating demand,but in different ways. With this approach,the public sector and NGOs focus ongeneric demand creation, leaving supply,distribution and brand-specific promotion

to the private sector and social marketingprogrammes.

Demand creation is a medium- to long-term approach, to ensure that any marketit helps to develop is sustainable. It can betargeted to specific geographical areas butis not usually targeted to vulnerable groups,because the primary aim is to stimulategrowth of a sustainable commercial market.


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1.3.2 Sustained subsidies for equity

(targeting vulnerable groups)

A sustained subsidies for equity approachaims to ensure that vulnerable populationgroups have access to ITNs. The poorest,and those most at risk of malaria, may notbe protected if net distribution is left to thecommercial sector. While it is easy to identifybiologically vulnerable groups, such aschildren under five and pregnant women,it is more difficult to reach consensus in acommunity about which households are

the poorest. In larger scale programmes,targeting based on biological vulnerabilityis likely to be more feasible than targetingbased on socioeconomic status. Sustainedsubsidies for equity is a long-term approach.The potential for going to scale is limitedby the size of the vulnerable populationgroups and by available resources. Sustainedsubsidies for equity can target specificgeographical areas, if appropriate.

This approach needs to be carefullyplanned and controlled to ensure thatit complements efforts to expand thecommercial market. It requires effectivetargeting mechanisms to ensure that only

Figure 5 The balance between equity and sustainability

Source: Insecticide-treated nets in the 21stcentury: report of the 2ndinternational conferenceon insecticide-treated nets. Malaria Consortium /WHO/USAID/UNICEF/MoH United Republicof Tanzania, 2000.

High Low

Low HighLow High

Price

CoverageHealth impact

Sustainability Equity

Setting prices in projectsSetting prices in projects

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17

Introd

the intended population groups benefitfrom no-charge or highly subsidized nets

and insecticides. Ineffective targeting cansubsidize those who do not need it,diverting sales from the commercialmarket, or lead to the development ofan illegal market where people sell netsat a profit.

There is limited experience of tightlycontrolled targeting of ITNs, with theexception of Malawi and the UnitedRepublic of Tanzania, where Population

Services International (PSI), a socialmarketing organization, has been targetingpregnant women with nets that are morehighly subsidized than other brands.

Nets provided at no charge by PSI aresold by health workers to antenatal clinicattendees at a subsidized price, and thehealth workers retain a small commissionfor each net sold. These subsidized nets aredifferentiated, by colour and brand, from

those sold in the commercial market.Chapter 5 provides more information abouttargeting vulnerable groups; and Chapter 7more information about social marketing.

1.3.3 Revolving fund

A revolving fund approach aims to sell netsand insecticides at prices that cover all thecosts of an ITN intervention, not just thecost of the nets and insecticides, to replenishand maintain the initial fund.

A revolving fund is a long-term approach.Few programmes, however, have been ableto establish revolving funds that are trulysustainable.

The potential for going to scale is limited

by the size of the initial fund and salesrevenue. Revolving funds can be targetedto specific geographical areas but are notusually targeted to vulnerable groups,because the primary aim is to recover allcosts. This approach competes with or maysubstitute for private sector sales, but willnot undermine the market, because netsand insecticides are sold at similar prices.


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1.3.4 Social marketing

A social marketing approach aims toincrease demand in the commercial market(the crowding in or halo effect) inorder to increase sales both of sociallymarketed branded nets and of non-programme nets. It may also aim toprovide subsidized nets and insecticides tosocioeconomically or biologicallyvulnerable population groups. Asdiscussed above (see section 1.3.2)it is more feasible to target biologically

vulnerable groups than socioeconomicallyvulnerable groups, and there has beenlimited experience with tightly controlledtargeting of specific population groups.Social marketing can and has been usedto target specific geographical areas,depending on available delivery channelsand outlets. Social marketing is a long-termapproach. The availability of donor funds,however, limits both the time-scale and

potential for going to scale with socialmarketing.

Although this approach aims to stimulatedemand in the commercial market, it hasthe potential to undermine the privatesector because of unequal competition.

For example, donor-funded socialmarketing programmes may benefit from

tax and tariff exemption that is notavailable to commercial suppliers, enablingprices to be set lower than those in thecommercial market. Price levels, usuallysimilar to or slightly lower than those inthe private sector, depend on the level ofcost recovery to be achieved. The evidenceabout positive or negative impact of socialmarketing on the growth of the commercialsector is conflicting and more information

is needed. Negative impact can be avoidedby limiting the duration of social marketingprogrammes, in the same way aspump-priming, or by limiting the quantityof nets distributed to a small proportionof those distributed by the retail market.Social marketing can also play a role indemand creation alone, without involvementin distribution of nets and insecticide.

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19

Intro

1.3.5 Pump-priming

A pump-priming approach aims tostimulate demand in the commercialmarket. New customers are encouragedto buy nets at lower prices than theprivate sector. The intention is that theywill use and like using a net and will buya replacement when needed from thecommercial market, and that theirneighbours will also be encouraged toacquire nets. This is a short-term approach.Selling nets at lower prices than the private

sector in the medium or long term willundermine the commercial market.Pump-priming can be targeted to specificgeographical areas and vulnerable groups.

1.3.6 Emergency relief

An emergency relief approach aims to makenets and insecticides available to refugeeand internally displaced populations incomplex emergency situations. This is ashort-term approach. It can become longterm in chronic complex emergencies,however, and ITNs are likely to be a moreappropriate intervention in the chronicphase of emergencies. Emergency relieftargets the specific geographical areasthat people have moved to. It can target

biologically vulnerable groups. Targetingsocioeconomically vulnerable groups isnot likely to be necessary in the acutephase of emergencies but may be desirablein the chronic phase of complex emergencies.The acute phase is defined as the periodwhere crude mortality rate is above onedeath per 10 000 per day, while the chronicphase is a longer-term situation characterizedby some areas remaining in an acute

phase while others move towards the post-emergency phase.


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Approach Intended durationof intervention

Scope for goingto scale

Pricing policy Targeting of deliveryby geographical area

Targeting of deliveryby socioeconomicstatus (the poor)and/or by biological

vulnerability tomalaria (childrenunder five andpregnant women)

Intended impact oncommercial market

Indicators ofoperational success

Demand creation Medium- to long-term Unl imited Market forces Possib le dependson size/scale ofmarkets and reachof promotion

No Stimulationof demand

Commercial salesvolumes

% coverage Cost-effectiveness

of demand creation

Sustained subsidiesfor equity

Long-term Limited by sizeof target group

No-chargeor low prices

Possible Essential Complementary(may stimulatedemand innon-target groups)

% additional coveragein target groups

Effectiveness oftargeting (leakage to

non-target groups) Cost per net deliveredto target group

Revolving fund Long-term Limited by resources Price must coverall costs(includingdistribution, handling,administration)

Possible Usually undesirable

selling to all helpsto spread fixed costs,therefore keepingprices down

Competition/substitution

Project sales volumes Financial viability

(independence fromsubsidy)

Cost per net delivered % coverage

Social marketing Long-term Limited by resources Similar or lowerthan the commercialmarket

Possible dependson delivery channels

Some segmentationpossible

Stimulationof demand(crowding inor halo effect)

Project sales volumes Commercial sales

volumes % coverage Cost per net delivered

Crowding in versuscrowding-out

Pump-priming Short-term Limited by time Low prices(to encourage take-up) but not too low(to reduce perceivedvalue)

Possible Possible Stimulationof demand

Increased sales incommercial market(usually post-intervention)

Cost effectivenessof demand creation

Emergency relief Short-term Limited No-charge or verylow prices (Equity)

Essential Biological targetingpossible, buteconomic targetingunlikely

Irrelevant Number of ITNsdelivered

% coverage intarget groups

Table 1.2 Potential approaches to ITN interventions

O p e r a t i o n a l c h a r a c t e r i s t i c s a n d i n d i c a t o r s


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Chapter 2


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It is important to assess the current

ITN situation and the factors that

determine the choice of strategy

before deciding what ITN strategyis appropriate for the country or

organization, and before planning

a national strategy or a programme.

T

his chapter describes what needs tobe assessed and how to determinewhat needs to be known.

The most important aspectsof assessment are:

institutional and policy factors;

malaria epidemiology and population

factors;

net and insecticide factors;

knowledge and attitude factors.

Assessment


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23

Assessment

2.1 Institutional and policy factors

The main factors to assess are: NMCP mandate and scope programmatic,geographical, duration;

policy context international, national;

other organizations NGOs, socialmarketing programmes;

commercial sector.

2.1.1 Organizational mandate and scope

The mandate of the NMCP and of otherorganizations is the main factor thatdetermines the strategy adopted for ITNinterventions. As discussed in Chapter 1,for example, an organization with amandate that emphasizes poverty andequity is likely to take an approachinvolving targeting the most vulnerablepopulation groups with no-charge orsubsidized ITNs.

Another important strategic issue to consideris geographical scope. For example, theNMCP will have a national mandate, butother organizations, such as NGOs, mayfocus their efforts in certain regions ordistricts. The time that an organizationintends to devote to ITNs is also animportant factor, as some strategies requirelonger-term intervention than others.

The following questions should be used to help to

identify current activity and gaps in implementation: What is the mandate of the NMCP and of other

organizations in terms of reaching specific targetgroups, achieving sustainability, ensuring equity?

What is the geographical scope of the NMCPand other organizations?

What is the time-scale of ITN interventions bythe NMCP or by other organizations?

How do ITNs fit into the overall policiesand strategies of the NMCP?

How well developed is the commercial marketfor nets and insecticide?

Are there any other organizations workingon ITNs or related areas with which partnershipsmay be formed?


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2.1.2 International and national context

The national ITN strategy should fit within

the international policy and strategicframework. RBM sets out clearly the roleof ITNs in malaria control. At national level,approaches adopted by social marketingprojects, NGOs and other organizationsshould function within the national strategyfor ITNs.

2.1.3 Other organizations

NMCP managers need to be aware of otherorganizations that are implementing ITNinterventions, what approaches they areusing, where they are working, and whatimpact they have achieved.

Competition should be avoided, unlessit is within the private sector. One of themost important functions of the NMCPis to promote collaboration andcomplementarity of activities.

Figure 6 Many factors have to be assessed when decidingwhether a treated net project is feasible

Source: Chavasse D, Reed C, Attawell K. Insecticide-treated net projects:a handbook for managers. Malaria Consortium, 1999.


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Assessment

2.1.4 The commercial market

It is also important to assess the size and

penetration of the commercial marketin nets and insecticide, since this willdetermine what role government and otherorganizations should play, and whatmeasures might be required to supporta larger role for the private sector. Forexample, if the private sector is alreadyproviding these commodities, care isneeded to ensure that interventions donot undermine the market.

2.2 Malaria epidemiologyand population factors

The main factors to assess are:

malaria epidemiology, vector speciesand biology;

population demographic data,vulnerable groups, socioeconomic status.

The following questions should be used to help toidentify target areas and populations:

What are the levels of malaria endemicity andtransmission in the country?

Are there variations in endemicity andtransmission in different parts of the country?

Is malaria transmission stable or unstable?

Will climatic or epidemiological factors affectthe feasibility of ITN interventions?

What is the biology and behaviour of the malariavectors?

What is the total population and the distributionof the population?

What population groups are most vulnerable?

What is the distribution of vulnerable groupssuch as children under five and pregnant women?

Are there refugees or internally displaced persons?

What is the socioeconomic status of the population?


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2.2.1 Malaria epidemiology

Malaria can be divided into four levels of

endemicity and transmission, as describedin Box 2. Malaria can also be epidemic.Malaria endemicity and transmission levelsvary greatly within countries, and there canbe considerable differences even within arelatively small area.

Levels of endemicity and transmission areaffected by climate and population factors.

Climate factors include temperature and

rainfall. Malaria is usually absent at highaltitudes because of low temperatures.The altitude limit for malaria transmissionis highest near the equator and decreasesas distance from the equator increases.So in an area with different altitudes, theremay be high malaria transmission in low-lying plains but no transmission in higherhills and mountains. In many countries,malaria transmission increases during orjust after the rainy season, because heavyrainfall increases the number of breedingsites for vectors such as A. gambiae.In areas with transmission all year round,there may still be a peak during or just afterthe rainy season. In contrast, in some partsof South Asia, failure of the rains leadsto increased transmission, because vectorssuch as A. culcifaciesprefer to breed inshallow water.

Figure 7. Making a simple map can help in assessing areas of high malaria transmission

Source: Chavasse D, Reed C, Attawell K. Insecticide-treated net projects: a handbook for managers.Malaria Consortium, 1999.


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Assessment

Population factors include patternsof agricultural land use and irrigation,

urbanization and economic activity. In partsof Africa, irrigated rice fields provide a goodbreeding site for A. gambiaeand malariatransmission will increase if these fields aresited close to population centres. In parts ofSouth Asia, A. stephensihas adapted to theurban environment by breeding in waterstorage tanks.

In areas where malaria is stable, ITNsare likely to have less effect on levels of

transmission than in areas of unstablemalaria, where they may reduce transmissionlevels in addition to providing personalprotection.

2.2.2 Vector species and biology

Different species of Anophelesbehavedifferently in terms of what, when andwhere they bite, and where they restafter biting. Table 2.1 summarizes the

characteristics of some of the mainmalaria vectors in Africa and Asia. Thesecharacteristics can vary between countriesand at different times, so it is important toobtain accurate, up-to-date national andlocal sources of information (see Table 2.2).

Box 2 Malaria endemicity and transmission

HoloendemicAreas with perennial high-degree transmission producingconsiderable immunity in all age groups, particularlyadults (parasite rate in infants constantly over 75%).

Hyperendemic

Areas with intense but seasonal transmission whereimmunity is insufficient to prevent effects of malaria in allage groups (parasite rate in children of 29 years oldconstantly over 50%).

MesoendemicTypically found in rural communities with varying intensityof transmission (parasite rate in children of 29 yearsold as a rule 1150%).

Hypoendemic

Areas with little transmission and malaria does notaffect the general population significantly (parasite ratein children of 29 years old as a rule less than 10%).


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Anopheles species Biting site Biting time Resting site Host preference ITN suitability

A. gambiae Indoors Mainly late Mainly indoors Mainly human +++

Breeding sites

Sunlit temporary pools, rice fields

A. arabiensis Indoors and outdoors Mainly late Indoors and outdoors Human and animal + Temporary pools, rice fields

A. melas Indoors and outdoors Mainly late Indoors and outdoors Human and animal + Saltwater lagoons, mangrove swamps

A. merus Indoors and outdoors Mainly late Indoors and outdoors Mainly animal +/ Saltwater lagoons, mangrove swamps

A. funestus Indoors Mainly late Indoors Mainly human +++ Semi-permanent and permanent waterwith vegetation, swamps, slow streams,

ditch edges

A. dirus Indoors and outdoors Mainly late Mainly outdoors Mainly human +/ Small shady pools in forest and plantations,footprints, streams, wheel ruts,

gem pits, hollow logs, wells

A. minimus Mainly outdoors All night Mainly outdoors Human and animal +/ Streams in forested foothills

Sunlit streams, ponds, tanks,riverbed pools

A. sundaicus Indoors and outdoors All night Indoors and outdoors Human and animal +/ Brackish or salt water near coasts,

rock pools, river mouths

A. culicifacies Indoors and outdoors Peak biting21.0023.00 hours

Mainly indoors Mainly animal +/ Clean and polluted habitats, irrigation ditches,rice fields, swamp pools, wells, borrowpits, edges of streams. Prefers breeding

sites associated with slight rain

Table 2.1 Characteristics of Anophelesvectors in Africa and Asia

A. maculatus Mainly outdoors Peak biting19.0024.00 hours

Mainly outdoors Mainly animal


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Assessment

A. superpictus Indoors and outdoors Mainly early evening Indoors Mainly animal Prefers flowing waters, such as shallowwater over rocky streams, pools in rivers,

muddy hill streams and wherevegetation is present

A. stephensi Indoors and outdoors Peak b it ingbefore 24.00 hours

Indoors Animal Urban cisterns, wells, gutters, pollutedwater; rural grassy pools and

alongside rivers

A. sacharovi Indoors and outdoors All night Mainly indoors Human and animal +/ Brackish water of marshes, pools andponds, especially with vegetation.

Prefers sunlit habitats

A. pulcherrimus Indoors and outdoors Evening and night Indoors and outdoors Mainly animal Weedy irrigation channels, marshes, cleanstagnant water with or without vegetation,slow moving streams, ditches, rice fields

Source: Adapted and expanded from Mehra, S & Malaria Consortium. Partnerships for change and communication: guidelines for malaria control.WHO/Malaria Consortium, 1997.

A. barbirostris Indoors and outdoors All day long Mainly indoors Mainly animal, buthuman in some

locations

Swamps or ponds with some vegetation.Prefers partial shade. Larvae often occurin shaded corners of rice fields, ditches,

earthen wells, sometimes brackish water

A. aconitus Indoors and outdoors Peak b it ingaround 24.00 hours

Indoors and outdoors Human, sometimesanimal

+/ Larvae occur in rice fields , swamps, i rr igationditches, pools, and streams with vegetation.

Prefers sunlit habitats

A. subpictus Indoors and outdoors Evening feeders Indoors and outdoors Human and animal +/ Muddy pools near houses, gutters, borrowpits, and brackish water

A. annularis Mainly outdoors Eveningending by 23.00 hours

Mainly outdoors Mainly animal Larvae occur in rain-fed tanks, vegetationand irrigation canals


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ITNs are most likely to reduce malariatransmission where malaria vectors:

bite indoors; bite at night when people are asleep;

rest indoors;

bite humans preferentially.

2.2.3 Demographic data

The most accurate information availableabout the total population of the country,its regions and districts, should be obtained

from the census or from other sources ifthe census is out of date. Data should alsobe collected about the size of vulnerablegroups, for example the proportion of thepopulation who are under the age of fiveyears, or pregnant, or with the lowestsocioeconomic status.

It is also important to assess whatproportion of the population is at risk fromstable endemic malaria or from epidemic

malaria. The MARA (Mapping Malaria Riskin Africa) web site (see Table 2.2) presentsmodels of malaria distribution andestimates of populations at risk of malaria.

2.2.4 Vulnerable groups

The risk of malaria infection depends onthe risk of being bitten by an infected

mosquito, which itself depends on levelsof transmission and exposure. The risk of

infection leading to severe malaria diseasedepends on a persons immune status andaccess to treatment. Within populationsat risk of malaria, certain groups areparticularly at risk of infection the poor,refugees and internally displaced persons or of severe disease children under fiveand pregnant women.

Children under five years of age have notyet developed protective levels of immunity

because they have had limited exposureto malaria. In areas of high transmission,young children are both at high risk ofmalaria infection and vulnerable to severemalaria disease when infected. This is whychildren under five are usually one of themain target groups for malaria controlinterventions.

Pregnant women are also an importanttarget group for malaria control interventions.The protective immunity that adults developin areas of high or moderate transmissionis impaired during pregnancy. In such areas,pregnant women with symptomatic malariaoften have severe anaemia, and low birthweight is a common outcome. In areas oflow transmission where adults do notdevelop protective immunity, malaria


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Source

Institutional and policy factors:

Organizational scope Organizational strategy papers and plans, reviews andconsultancy reports.

International and national context RBM strategy, NMCP strategies and plans.

Other organizations Umbrel la organizat ion reports, NGO and otherorganization reports.

Commercial market NetMark19, market research organizations, commercialorganizations.

Malaria epidemiology and population factors:

Malaria epidemiology MARA, other national-level Geographical InformationSystems, NMCP survey data, research institutions anduniversities, projects and programmes, regional healthmanagers, district health managers.

Vector species and behaviour NMCP, research institutions and universities, projectsand programmes, regional health managers, districthealth managers.

Vulnerable groups Census data, MOH, Demographic and Health Survey,reports by organizations such as UNICEF The State ofthe Worlds Children, The World Health Report, nationalpoverty statistics and Living Conditions Survey, Office ofthe United Nations High Commissioner for Refugees(UNHCR) reports, NGO reports.

Internet:

www.mara.org.za Maps of cl imatic suitabi li ty for the t ransmission of stablemalaria, duration of the transmission season, first and

last month of transmission, data on population at risk ofstable endemic and epidemic malaria.

www.rbm.who.int Wide range of information on RBM progress and relatedmalaria issues.

www.unhcr.org Refugee and internally displaced persons situation in avariety of countries.

www.idpproject .org Global IDP database of the Norwegian Refugee Counci l.

31

Assessment

infection in pregnancy is associated withsevere disease and high maternal and

perinatal mortality.The poor are often at greater risk of infectionand of severe disease, because of lackof information about what causes malariaand about how to prevent and treat it, andbecause measures to prevent and treatmalaria are not financially or physicallyaccessible. In addition, the poor have lowerimmunity because of disease and poornutrition, and higher exposure because

of inadequate housing and drainage.Refugees, internally displaced persons, and

migrant or seasonal workers who movefrom areas of no transmission or lowtransmission to highly endemic areas areat particular risk of infection, because theylack protective immunity. Even in countriesthat are generally highly endemic, urbanpopulations displaced to rural areas, wheremalaria risk is often higher, are vulnerable.

In this situation, all age groups will be atrisk of severe malaria. Conversely, non-immune populations in areas of no or lowtransmission may be at increased risk froman influx of people displaced from a highlyendemic area.

19 NetMark is a public-private partnership for the promotion of a commercially sustainable market forinsecticide-treated materials in the Africa region. More information is available from the NetMark web site:http://www.netmarkafrica.org.

Table 2.2 Sources of information


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2.3 Net and insecticide factors

The main factors to assess are:

current distribution and use of netsand insecticide;

types of nets people prefer;

ability and willingness to pay.

2.3.1 Net and insecticide

distribution and use

Methods for finding out about net andinsecticide availability and cost and for

assessing current use of nets and insecticide,include:

household survey

interviews and questionnaires

focus group discussions

commercial retail survey

existing data.

Household surveys can be used to observewhat proportion of households has a net,what types of nets are used, and whosleeps under nets. Household surveys canbe expensive and time-consuming, but awell-designed randomized survey canprovide baseline information about netcoverage. This is useful for evaluation,if increasing coverage is an objective ofthe intervention. Information should berecorded about the size, shape, colour,condition, source, and brand name of nets,

The following questions should be used to help to

decide what actions are required by the NMCP toensure effecti

Documents

WHO Mosquito Net