insecticide-treated mosquito net interventions -...
TRANSCRIPT
World Health Organization
Insecticide-treatedmosquito netinterventions
A manual for national control programme managers
E d i t e d b y R O L L B A C K M A L A R I A
World Health OrganizationGeneva, 2003
Insecticide-treatedmosquito netinterventions
A manual for national control programme managers
E d i t e d b y R O L L B A C K M A L A R I A
WHO/CDS/RBM/2002.45
ROLL BACK MALARIA is a global partnership founded by the governments of malaria-afflicted countries, the World Health Organization, the UN Children’s Fund, the World Bank and the UN Development Programme. Its objective is to halve the burden of malaria for the world’s people by the year 2010 by saving lives, 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 OrganizationCH–1211 Geneva 27– Fax: +(41) 22 791 4285 – E-mail: [email protected] control: Communications team of the WHO Programme on Communicable diseases Designed 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 services 5. 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viiList of abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ixPreface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xAcknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xii
CHAPTER 1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Implementation experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.1.1 Nets before ITNs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.1.2 Efficacy and effectiveness trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41.1.3 Early ITN projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71.1.4 Moving from projects to programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.2 Developing national ITN strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101.2.1 Bringing partners together . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101.2.2 Assessing the capacity of the commercial sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.2.3 Creating an enabling environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121.2.4 Establishing partnerships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.3 Potential approaches to ITN interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151.3.1 Demand creation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151.3.2 Sustained subsidies for equity (targeting vulnerable groups) . . . . . . . . . . . . . . . . . . . . . . . . 161.3.3 Revolving fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171.3.4 Social marketing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181.3.5 “Pump-priming” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.3.6 Emergency relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
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CHAPTER 2 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.1 Institutional and policy factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232.1.1 Organizational mandate and scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232.1.2 International and national context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242.1.3 Other organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242.1.4 The commercial market . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.2 Malaria epidemiology and population factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252.2.1 Malaria epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262.2.2 Vector species and biology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272.2.3 Demographic data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302.2.4 Vulnerable groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
2.3 Net and insecticide factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322.3.1 Net and insecticide distribution and use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322.3.2 Net preferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342.3.3 Ability and willingness to pay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
2.4 Knowledge and attitude factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362.4.1 Perceptions about malaria, its causes and prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362.4.2 Perceptions about nets, insecticides and ITNs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382.4.3 Sources of information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
CHAPTER 3 Planning, monitoring, and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.1 Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423.1.1 Developing a national strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423.1.2 Developing a framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443.1.3 Staffing, training, and supervision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453.1.4 Budgeting and funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453.1.5 Planning monitoring and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
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3.2 Monitoring and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473.2.1 Indicators for monitoring and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 483.2.2 Methods for measuring indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
CHAPTER 4 Sourcing and procurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
4.1 Nets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614.1.1 Types of nets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614.1.2 Quantity of nets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 644.1.3 Sources of nets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
4.2 Insecticides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 674.2.1 Type of insecticide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 684.2.2 Insecticide formulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 694.2.3 Packaging and labelling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 704.2.4 Quantity of insecticide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 724.2.5 Sources of insecticide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 724.2.6 Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 734.2.7 Efficacy monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
4.3 Ordering systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
CHAPTER 5 Financing and distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
5.1 Financing options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 815.1.1 No-cost recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 815.1.2 Partial-cost recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 815.1.3 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 956.2.1 Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 956.2.2 Implementing agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 956.2.3 Target audience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 966.2.4 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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1087.3.1 Nets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1087.3.2 Insecticide treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1087.3.3 Branding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1097.3.4 Market segmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
7.4 Price . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1107.4.1 Pricing structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1107.4.2 Cost recovery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1107.4.3 Subsidies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
7.5 Place . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1127.5.1 Distribution channels and outlets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
7.6 Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Contents
vii
List of tables and figures
Tables1.1 Impact of ITNs on overall mortality, mild malaria disease, parasitaemia
and anaemia, measured under programme conditions1.2 Potential approaches to ITN interventions2.1 Characteristics of Anopheles vectors in Africa and Asia2.2 Sources of information2.3 Perceptions that may enable or block the introduction of ITNs3.1 Potential roles and responsibilities of different partners3.2 Framework for a monitoring and evaluation plan3.3 Impact indicators3.4 Purpose indicators3.5 Output indicators3.6 Data collection tools for impact indicators3.7 Example of a logical framework for a social marketing strategy4.1 Insecticides recommended for net treatment4.2 Advantages and disadvantages of different approaches to ordering5.1 Financing options5.2 Selecting the most appropriate financing option5.3 Selecting the most appropriate pricing policy5.4 Distribution of nets and insecticides5.5 Delivery of nets5.6 Delivery of insecticides for net treatment6.1 Using assessment of current KAP to develop promotion objectives
viii
Figures1 Overview of planning ITN interventions2 The relationship between ITNs and malaria mortality: the example of Viet Nam3 The repellent effect of the insecticide deters mosquitoes from entering the room. A treated
net 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 sustainability6 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 transmission8 It is important to assess community interest in treated nets and to secure community
commitment9 Developing a project framework, comprising purpose, outputs and activities10 A sample tool for monitoring net coverage. Measuring household coverage of ITNs is an
important indicator in Roll Back Malaria11 Focus group discussions can help to assess changes in perceptions about nets12 Nets are available in a number of different shapes and sizes13 Washing nets in a bucket or bowl rather than a stream prevents insecticides contaminating
water sources. Wring the net gently. Gloves should be worn when washing or treating nets14 Nets can be provided at no-charge or at low prices to target vulnerable groups, such as
children under five and pregnant women15 Barriers to behavioural change16 Drama or role play, the radio, and personal communication are all methods that can be used
to promote ITNs17 It is important to pre-test promotional materials with a smaller group before using them with
the wider community18 Understanding the target audience is a vital part of social marketing19 Sales agents that travel to communities can make nets more accessible
List of tables and figures
ix
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 volumePSI Population Services InternationalRBM Roll Back MalariaSC Suspension concentrate [insecticide formulation]UNHCR Office of the United Nations High Commissioner for RefugeesUNICEF United Nations Children’s FundUSAID United States Agency for International DevelopmentWT Water dispersible tablets [insecticide formulation]WHO World Health OrganizationWHOPES WHO Pesticide Evaluation Scheme
List of abbreviations
x
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 needfor 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.
Preface
xi
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 contributor to child mortality will be well received by the fund. The fund managers will probably be looking forsigns of synergy in efforts to tackle the three diseases, so malaria planners would be wise to seek out 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 DOTS for 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 Geneva
December 2002
Preface
xii
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-treatednet 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 projects handbook.
Acknowledgements
Introduction
Chapter 1
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 aspectof ITN interventions:• Chapter 2 Assessment• Chapter 3 Planning, monitoring
and evaluation• Chapter 4 Sourcing and procurement• Chapter 5 Financing and distribution• Chapter 6 Promotion• Chapter 7 Social marketing
Introduction
3
Intro
duct
ion
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 DISTRIBUTION
Chapter 5
PLANNING, MONITORING AND EVALUATION
Chapter 3
FURTHERASSESSMENT
INITIAL ASSESSMENT
Determine financing for nets
and insecticide
Determine financing for
other components
Define pricing policy for nets and insecticide
Plan distributionmechanisms for
nets and insecticide
Plan outlets for nets 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
Formative research
Definecommunication
objectives
Develop messagesand determinecommunication
channels
Pre-test and modifystrategy
ADOPT A STRATEGY
4
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 nets
before the development of ITNs as a newtechnology;
• 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 challengesto 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 nets prior 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 controlled trial, i.e. almost ideal, conditions.
• Effectiveness is measured as impact under programme, rather than trial, conditions.
5
Intro
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ion
To evaluate the potential of ITNs, efficacy
trials were carried out in countries with awide 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 1–59 months),incidence of severe malaria, incidence ofuncomplicated malaria episodes, prevalenceof parasitaemia, mean haemoglobin level,splenomegaly, and nutritional status.
A Cochrane review1 concluded that ITNsreduce overall mortality by about 20% inAfrica (range 14–29%2, 3, 4, 5) and that, forevery 1 000 children aged 1–59 monthsprotected by ITNs, about six lives are savedeach year. The review also concluded thatITNs reduce clinical episodes of uncom-plicated malaria caused by Plasmodiumfalciparum 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 trials
were 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):855–62.
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):147–54.
4 D’Alessandro U et al. Mortality and morbidity from malaria in Gambian children after introduction of animpregnated bednet programme. Lancet, 1995, 345:479–83.
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):139–46.
14 000
12 000
10 000
8 000
6 000
4 000
2 000
090 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
6
6 Impact under operational conditions.7 D’Alessandro U et al. Mortality and morbidity from malaria in Gambian children
after introduction of an impregnated bednet programme. Lancet, 1995,345:479–83.
8 Matched with health centre controls.9 Matched with village controls.10 D’Alessandro U et al. The Gambian National Impregnated Bed Net Programme:
evaluation of effectiveness by means of case-control studies. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1997, 91:638–642.
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):23–9.
14 Abdulla S et al. Impact on malaria morbidity of a programme supplyinginsecticide-treated nets in children aged under 2 years in Tanzania: communitycross sectional study. British Medical Journal, 2001, 322:270–273.
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):1241–1247.
Table 1.1 Impact of ITNs on overall mortality, mild malaria disease, parasitaemia and anaemia, measured under programme conditions
Country Study Impact (protective efficiency6) Source
Overall mortality Mild disease Parasitaemia Anaemia(fever and
parasitaemia)
Gambia Longitudinal 25–40% D’Alessandrosurveillance et al. (1995)7
Gambia Case control 0% 59%8 D’Alessandrostudy 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
7
Intro
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Measuring effectiveness is more difficult andmethods used have included population-basedactive 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 of
implementation (e.g. organizationalmandate, historical presence);
• transmission intensities and vectors in the implementation area;
• indicators for monitoring and evaluation;• target group or population;• type and variety of nets and insecticide
supplied;• distribution mechanism for nets and/or
insecticide;• 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 entering the room (1). A treated net provides protection to the people sleepingunder 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)
8
• 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 ordistricts 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 proportion of the total population at risk of malaria. As a result, access to ITNs is still low in 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, there has been increasing recognition of theneed to go to scale from small projects to 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 cost of an untreated net in countries where netsare widely available. It would require US$ 200 million a year to provide 50 millionnets and a further US$ 25 million a year
9
Intro
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ion
to treat these nets with insecticide. This is too costly for users alone or donors(or governments). There are variouspossible approaches to cost sharing:
• Both donor and user contribute to each
ITN. 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 controlled to prevent “leakage” to the non-targetpopulation and the development of an illegal market in no-charge nets.
• Donors contribute to ITNs for some target
groups. 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 to“cross-subsidize” lower priced nets forpoorer groups.
• Users pay for nets and donors pay for
insecticides, or vice versa. This is the
approach used in China, the Gambia andViet Nam. The population is responsible forbuying 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 limited
experience with going to scale and nationalcoverage has only been achieved in a fewcountries, 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.
10
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 alreadydeveloped national ITN strategies. Keysteps in developing a national ITN strategyinclude:• bringing together potential partners;• assessing the capacity of the commercial
sector;• creating an enabling environment for
ITNs;• 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 fitwithin 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 thatthis is the way forward for the nationalstrategy, partners need to agree on howbest to create an enabling environment for growth of the commercial sector andhow best to identify and target populationgroups unlikely to be reached by thecommercial sector. It is also important to ensure that any current or planned ITNprogrammes implemented by the publicsector or NGOs do not undermine the
11
Intro
duct
ion
growth of the commercial sector. If possible, such programmes should bedesigned 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 51–76% 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 Tanzania
In 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 nets a 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 D’Alessandro U et al. Nationwide survey of bednets in rural Gambia. Bulletin ofthe World Health Organization, 1994, 72(3):391–4.
18 Webster J et al. Review of household coverage of nets in non-project areas ofsub-Saharan Africa. Malaria Consortium, 2001.
12
Unlike nets, the commercial market ininsecticides for net treatment is almostnon-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 of a commercial market, although the likelynature and size of this market has yet to be determined.
1.2.3 Creating an enabling environment
There is no standard definition of“an enabling environment” nor are therespecific guidelines for creating an enablingenvironment. This is because the situationand the national strategy will be different in each country, and the action requiredto create an enabling environment willdepend on the current status of thecommercial net and insecticide market.However, two important aspects of anenabling environment in every context are 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
• Transitional opening up of markets:
market priming • Ensuring access for
vulnerable groups
• Local demand creation
• Additional niche supply to specialtarget populations
(e.g. refugees)
• Brand specific demand creation
• Distribution to general population
at commercialprice
• Product development
• Create enablingenvironment(e.g. taxes)
• Research
• Bring partners together
• National generic demand 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 participants involved in development ofthe Tanzanian national ITN strategy.
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Reducing taxes and tariffs can catalyseprocurement, manufacture and distributionof 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 malariaprevention 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 demandcreation, 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 manufactureand 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 sociallymarketed 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 marketis 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 Technology in Health (PATH) Canada, Basic Support for InstitutionalizingChild Survival (BASICS), commercial firms and the GhanaSocial 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 government’s 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, 6–9 March 2001.
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1.3 Potential approaches to 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 approaches will 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 required for 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 promotionto 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 arethe 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 21st century: report of the 2nd international conference on insecticide-treated nets. Malaria Consortium /WHO/USAID/UNICEF/MoH United Republic of Tanzania, 2000.
High Low
Low High
Low High
Price
Coverage
Health impact
Sustainability Equity
Setting prices in projectsSetting prices in projects
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the intended population groups benefitfrom no-charge or highly subsidized netsand 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 PopulationServices 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 are sold 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, fromthose 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 limitedby 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 biologicallyvulnerable 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 andpotential 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 fromtax 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 informationis needed. Negative impact can be avoidedby limiting the duration of social marketingprogrammes, in the same way as“pump-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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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 the private sector. The intention is that they will 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 privatesector 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 areas that people have moved to. It can targetbiologically vulnerable groups. Targetingsocioeconomically vulnerable groups is not 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 going to scale
Pricing policy Targeting of deliveryby geographical area
Targeting of deliveryby socioeconomicstatus (the poor)and/or by biologicalvulnerability tomalaria (childrenunder five andpregnant women)
Intended impact oncommercial market
Indicators ofoperational success
Demand creation Medium- to long-term Unlimited Market forces Possible – dependson size/scale ofmarkets and reach of promotion
No Stimulation of demand
• Commercial salesvolumes
• % coverage• Cost-effectiveness
of demand creation
Sustained subsidiesfor equity
Long-term Limited by size of target group
No-chargeor low prices
Possible Essential Complementary (may stimulatedemand in non-target groups)
• % additional coveragein target groups
• Effectiveness oftargeting (leakage tonon-target groups)
• Cost per net deliveredto target group
Revolving fund Long-term Limited by resources Price must cover all costs (includingdistribution, handling,administration)
Possible Usually undesirable
– selling to all helps to 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 lower than the commercialmarket
Possible – dependson delivery channels
Some segmentationpossible
Stimulationof demand(“crowding in” or “halo effect”)
• Project sales volumes• Commercial sales
volumes• % coverage• Cost per net delivered• “Crowding in” versus
“crowding-out”
“Pump-priming” Short-term Limited by time Low prices (to encourage take-up) but not too low (to reduce perceivedvalue)
Possible Possible Stimulation of demand
• Increased sales incommercial market(usually post-intervention)
• Cost effectiveness of demand creation
Emergency relief Short-term Limited No-charge or verylow prices (Equity)
Essential Biological targetingpossible, buteconomic targetingunlikely
Irrelevant • Number of ITNsdelivered
• % coverage in target 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
Assessment
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 strategy
is appropriate for the country or
organization, and before planning
a national strategy or a programme.
This chapter describes what needs tobe assessed and how to determinewhat needs to be known.
The most important aspects of assessment are:• institutional and policy factors;
• malaria epidemiology and population
factors;
• net and insecticide factors;
• knowledge and attitude factors.
Assessment
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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, social
marketing 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 toidentify 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 NMCP and other organizations?
◆ What is the time-scale of ITN interventions bythe NMCP or by other organizations?
◆ How do ITNs fit into the overall policies and strategies of the NMCP?
◆ How well developed is the commercial market for nets and insecticide?
◆ Are there any other organizations working on 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 withinthe 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, unless it is within the private sector. One of themost important functions of the NMCP is 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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2.1.4 The commercial market
It is also important to assess the size andpenetration 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 epidemiology and population factors
The main factors to assess are:• malaria – epidemiology, vector species
and 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 and
transmission in the country? ◆ Are there variations in endemicity and
transmission in different parts of the country?◆ Is malaria transmission stable or unstable?◆ Will climatic or epidemiological factors affect
the feasibility of ITN interventions?◆ What is the biology and behaviour of the malaria
vectors?◆ What is the total population and the distribution
of the population?◆ What population groups are most vulnerable?◆ What is the distribution of vulnerable groups
such 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 ofendemicity 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 andrainfall. 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. culcifacies prefer 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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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. gambiae and malariatransmission will increase if these fields aresited close to population centres. In parts ofSouth Asia, A. stephensi has adapted to theurban environment by breeding in waterstorage tanks.
In areas where malaria is stable, ITNs are likely to have less effect on levels oftransmission 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 Anopheles behavedifferently in terms of what, when andwhere they bite, and where they rest after biting. Table 2.1 summarizes thecharacteristics of some of the main malaria 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
Holoendemic
Areas 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 2–9 years oldconstantly over 50%).
Mesoendemic
Typically found in rural communities with varying intensityof transmission (parasite rate in children of 2–9 yearsold as a rule 11–50%).
Hypoendemic
Areas with little transmission and malaria does notaffect the general population significantly (parasite ratein children of 2–9 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 water with vegetation, swamps, slow streams,
ditch edgesA. 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 biting 21.00–23.00 hours
Mainly indoors Mainly animal +/– Clean and polluted habitats, irrigation ditches,rice fields, swamp pools, wells, borrow pits, edges of streams. Prefers breeding
sites associated with slight rain
Table 2.1 Characteristics of Anopheles vectors in Africa and Asia
A. maculatus Mainly outdoors Peak biting 19.00–24.00 hours
Mainly outdoors Mainly animal –
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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 where vegetation is present
A. stephensi Indoors and outdoors Peak biting before 24.00 hours
Indoors Animal – Urban cisterns, wells, gutters, polluted water; rural grassy pools and
alongside riversA. sacharovi Indoors and outdoors All night Mainly indoors Human and animal +/– Brackish water of marshes, pools and
ponds, 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 occur in shaded corners of rice fields, ditches,earthen wells, sometimes brackish water
A. aconitus Indoors and outdoors Peak biting around 24.00 hours
Indoors and outdoors Human, sometimesanimal
+/– Larvae occur in rice fields, swamps, irrigationditches, pools, and streams with vegetation.
Prefers sunlit habitatsA. subpictus Indoors and outdoors Evening feeders Indoors and outdoors Human and animal +/– Muddy pools near houses, gutters, borrow
pits, 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 obtainedfrom 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 epidemicmalaria. 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 levels of transmission and exposure. The risk ofinfection leading to severe malaria diseasedepends on a person’s immune status andaccess to treatment. Within populations at 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 immunitybecause they have had limited exposure to 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 transmission is 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
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 Umbrella organization 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 World’s 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 climatic suitability for the transmission of stablemalaria, duration of the transmission season, first andlast 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 Council.
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infection in pregnancy is associated withsevere disease and high maternal andperinatal mortality.
The poor are often at greater risk of infectionand of severe disease, because of lack of information about what causes malaria and 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 are at 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 nets
and 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 forassessing 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 of the intervention. Information should berecorded about the size, shape, colour,condition, source, and brand name of nets,
The following questions should be used to help todecide what actions are required by the NMCP toensure effective distribution of nets and insecticide: ◆ Are nets available? ◆ How many people already have a net?◆ What proportion of the poor own a net? ◆ How much do nets cost? ◆ Are nets available locally for less than US$ 10?◆ What types of nets do people currently use?◆ What types of nets would they prefer to use? ◆ Is insecticide available?◆ How many people use insecticide to treat their nets? ◆ What proportion of the poor use insecticide
to treat their nets?◆ How much does insecticide cost?◆ What is the average income? ◆ How much cash do people have? ◆ At what times of the year do people have cash?◆ What can people afford to pay for nets and
insecticide?◆ Who cannot afford to pay for nets and insecticide?
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and about sleeping habits. It is importantthat all investigators carrying out the surveyrecord the variables in the same way. Forexample, they need to be able to recognizethe same product as ready-made or stitchedand to describe sizes in the same way. Thesample of households does not need to bevery large, but it must include differentgroups of people, for example differentethnic groups, who may have differentpreferences and different sleeping habits.
Interviews and questionnaires can be usedto collect information from key informants,such as community leaders or health workers,and from a wider sample of people.Interviewers must take care not to lead theresponses of informants. Questionnairesdelivered through outlets such as clinicsand schools can be used to ask the samequestions about net characteristics.Questionnaires completed by respondentsrely on the description of the net by the netowner, however, and different individualsmay describe the same things in differentways.
Focus group discussions, involving a smallgroup of 6–8 people, can provide usefulinformation about people’s attitudes andbeliefs. The discussion is facilitated toensure that all participants are able to voicetheir opinions. It is important to make sure
that the participants are representative ofthe intended population or target group.
Commercial retail surveys, including retailoutlets, hawkers, local tailors who producenets, and other private sector providers, can provide valuable information about thenumbers and types of nets and insecticidessold.
Existing data from other programmes andprojects may provide information aboutcurrent and past distribution of nets andinsecticide. Other organizations, such associal marketing projects, may have dataabout net and insecticide coverage, useand sleeping habits.
Examples of some of the questions that should beused about net and insecticide distribution and useinclude:◆ Are nets available in your local shops or market? ◆ Do you have a net?◆ Where did you buy your net?◆ What type of net is it (size, shape, colour)?◆ Have you heard about ITNs?◆ Are ITNs available in your local shops or market?◆ Do you have an ITN? ◆ How many times has it been re-treated?◆ How often do you wash your ITN?
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Information about current distribution anduse will help to determine the strategiesadopted. For example, if most peoplealready have a net, it is not necessary to become involved in net distribution. If net use is low or inconsistent, it may be necessary to develop communicationactivities to encourage appropriatebehaviour. Similarly, if ownership amongthe poorest is low, targeted subsidies maybe required.
If most people do not have nets, however,it is important to find out why. For example,it may be necessary to improve theavailability of nets, or to investigatesourcing and procurement to ensure thatnets are available at reasonable prices, orto focus on marketing nets. If distribution is necessary, this should be done in a waythat avoids adverse effects on the growthof the commercial market, and that limitsthe scope and duration of public sectordistribution.
2.3.2 Net preferences
The nets that people use may be the typethey prefer, or the best of the availableoptions, or the only type available. In somesettings, lack of choice or dislike of the typeof nets available may be one reason whypeople do not own or use a net.
It is important to assess what type of netpeople would choose to use, based ona clear understanding of the range ofavailable options. Methods for assessingnet preferences include:• demonstration survey;• net placement survey;• existing data.
Demonstration surveys are surveys withstructured interviews, where the interviewersdemonstrate the range and relative costs ofthe nets available. This can be carried outat the same time as a household survey,demonstrating net options after assessingcurrent net use.
Net placement surveys are surveys wheredifferent types of nets, in a range ofcolours, sizes and shapes, are given toa sample of community members for aperiod of time, after which they are askedfor their views about the different options.
Existing data from other ITN surveys andprogrammes may provide informationabout net preferences.
2.3.3 Ability and willingness to pay
Assessment of ability to pay by themajority of the population or target groupis important to determine the price of netsand insecticide, if the interventions will
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include distribution of these commodities.Unless nets and insecticide will be providedat no charge, an assessment of whatpeople can afford to pay should be made.To do this, it is necessary to find out aboutaverage annual incomes, and seasonalityof income and cash availability.
Availability of cash depends on expenditureas well as income. For example, an urbanmanual labourer may earn a higher dailywage than a rural farmer, but may alsohave higher living costs – people in urbanareas need to buy food, whereas farmerscan grow most of their food. Communityincome and cash availability may also varyby season. For example, rural communitiestend to have more money directly afterharvest.
The seasonal availability of cash shouldalso be considered when planning thetiming of promotional campaigns. Ideallynets should be promoted both whenmalaria transmission is highest and whenpeople have cash to buy nets. If the timewhen people have money does notcoincide with the malaria season,promotion should be timed to coincidewith cash availability.
Assessment of who cannot afford to pay isimportant if the interventions will includetargeting subsidized or no-charge nets and
insecticide to the poorest. This will requirea more in-depth assessment—through asocioeconomic household survey—toidentify those in the community who cannotafford to pay.
Information about willingness to pay isless accurate than information about abilityto pay, and less useful in determining price.For example, if a person is asked howmuch they are willing to pay for something,they are likely to opt for a low value in thehope that this results in the price being setat a low level. Willingness to pay for ITNsalso depends on other household prioritiesand on the level of nuisance biting bymosquitoes. Unlike ability to pay, however,willingness to pay can be influenced bypromotional campaigns.
Examples of questions that should be asked aboutability and willingness to pay include:◆ What is your occupation?◆ How many children are there in your household?◆ Who controls the household budget?◆ Who decides about making household purchases?◆ Does this depend on the type of purchase?
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The following questions should be used to help todetermine what topics promotional messagesshould focus on and how best to promote ITNs:◆ What does the community know about malaria? ◆ How do people think malaria is transmitted?◆ What are people’s perceptions about mild
malaria? What are their perceptions about severemalaria?
◆ Who is considered to be vulnerable to malaria? ◆ How do people assess their own risk of malaria
infection?◆ What do people know about malaria prevention?◆ What are the perceptions about nets among net
users?◆ What are the perceptions about nets among non-
users of nets?
2.4 Knowledge and attitudefactors
The main factors to assess are:• perceptions about malaria, its causes
and prevention;• perceptions about nets, insecticides
and ITNs; • sources of information.
2.4.1 Perceptions about malaria,
its causes and prevention
An understanding of perceptions aboutmalaria, its causes and prevention, isimportant in assessing whether or not thepopulation will see the need for ITNs andbe willing to use them. Finding out aboutpeople’s perceptions is also important indeciding what messages to include in ITNpromotional campaigns.
The most common method for finding outabout perceptions is a Knowledge, Attitudeand Practice (KAP) survey. Other methodsinclude questionnaires, interviews, focusgroup discussions and review of existingdata. Whichever methods are used, inputfrom a social scientist with communityknowledge and experience is recommended.
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Malaria. An assessment of what peopleunderstand about malaria should be made.For example, their understanding of mild,febrile malaria may coincide with thebiomedical model of malaria, but theirunderstanding of severe, complicatedmalaria may be very different. In somecountries, cerebral malaria is consideredto be a different disease with differentcauses from uncomplicated malaria.
Malaria transmission. It is important to findout whether or not people understand therole of mosquitoes in malaria transmission,and are aware that not all mosquitoestransmit malaria. People need to know that malaria is transmitted by mosquitoes,if they are to understand the role of ITNsin preventing malaria by preventingmosquito bites.
Risk and vulnerability. It is also importantto assess perceptions about individual riskand vulnerable population groups. Even ifpeople have an understanding of the risk ofmalaria, they may not take steps to protectthemselves if they do not see that they arepersonally at risk. Communities may notalways recognize that young children andpregnant women are the most vulnerableto severe malaria disease.
Figure 8 It is important to assess communityinterest in treated nets and to securecommunity commitment
Source: Chavasse D, Reed C, Attawell K. Insecticide-treated net projects: a handbook for managers. Malaria Consortium, 1999.
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Examples of some of the questions that should beused about perceptions of malaria include:◆ What are the symptoms of malaria?◆ What causes malaria?◆ Who is most vulnerable to malaria?◆ What do you do to protect yourself from malaria?
2.4.2 Perceptions about nets,
insecticides and ITNs
Assessing the perceptions of net users andnon-users about nets, insecticides and ITNsis essential to inform the design of promotionand communication activities.
It may be more difficult to identify peoplewho have experience of using ITNs incommunities where treatment of nets is not common. It may be possible, however,to find people who have had experience of the effects of insecticide, either throughindoor residual spraying campaigns or useof insecticide sprays.
It is important to find out what motivatespeople to use nets, what prevents peopleusing nets, and whether there areimportant differences between users andnon-users of nets. For example, preventingnuisance biting is often a much strongermotivator for net and ITN use than preventing
malaria. Non-use of nets may be related tofactors such as gender, social status,education, culture, ethnicity, cost or access.
Questions that should be asked aboutperceptions about nets and insecticides canbe based on the following table of“enabling” and “blocking” perceptions:(see table 2.3)
2.4.3 Sources of information
The final factor to assess is where peopleobtain information about health issuessuch as malaria and about commoditiessuch as nets and insecticides.
The key sources of knowledge andinfluence in the community should beidentified because this information willinform the design of communicationactivities. These sources may includerespected individuals, such as communityor religious leaders, schools, health clinicsand the media. If the media is important,it will be necessary to find out how manypeople have access to radio, television andprinted material, as well as about literacylevels.
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Enabling perceptions Blocking perceptions
Perceptions of malaria • Priority disease• Serious and mild forms exist
• Mild disease with no serious or fatal outcomes
Malaria transmission • Transmitted by mosquitoes• Transmitted by a particular type of mosquito
• Transmitted in other ways
Existing net use • Tradition of using nets • Positive perceptions about nets: prevent malaria;allow a good night’s sleep; keep out other pests;provide privacy; are decorative
• Negative perceptions about nets: hot and no aircirculation; difficult to hang; fire hazard• Use other products, e.g. coils• Use only at certain times of the year• Nets washed frequently
Use of insecticides • Experience of mosquito and malaria reductionthrough indoor residual spraying programmes• Use insecticide sprays or other sprays for killinginsects within the home
• Toxicity fears
Use of ITNs • Positive perceptions about ITNs: prevent malaria;allow a good night’s sleep; kill bedbugs, fleas, headlice and mosquitoes
• Negative perceptions about ITNs: fear of side-effects (e.g. birth control); dislike of the smell
Table 2.3 Perceptions that may enable or block the introduction of ITNs
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Planning, monitoring, and evaluation
Chapter 3
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After conducting an assessment
(see Chapter 2), the next step
is planning, both to develop a
national strategy and to plan
an ITN programme or interventions
in more detail. A clear plan will also
help decide how to monitor and
evaluate the programme or
interventions. This chapter outlines
the main issues to consider in
planning, monitoring and evaluation.
3.1 Planning
The most important aspects of planning are:• developing a national strategy;• developing a framework;• staffing, training and supervision;• budgeting and funding;• planning monitoring and evaluation.
3.1.1 Developing a national strategy
The key elements of a national strategyinclude:• creating an enabling environment;• demand creation/promotion –
generic/brand specific;• supply of nets and insecticide;• distribution of nets and insecticide;• equity and vulnerable groups;• regulation – setting standard specifications
and registration of products;• advocacy for removal of taxes and tariffs;• quality assurance and quality control;• monitoring and evaluation;• operational research.
Planning, monitoring, and evaluation
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One of the aims of a national strategy isto ensure that the efforts of all partnerscomplement each other and contribute tothe same overall vision. In Ghana, Kenyaand the United Republic of Tanzania, forexample, national strategies are based on consensus about the need to create anenabling environment for the private sectorto expand the net market. If there is alreadya national ITN strategy and a body in placeto coordinate implementation of thestrategy, the roles of different partners willbe defined within the strategy and by thecoordinating body. If there is no strategy,one will need to be developed based on thefindings of the assessment (see Chapter 2).
All partners should be involved in:• reaching consensus on the vision for
the future and on the actions needed toachieve this vision;
• assessing the strengths and weaknessesof each partner and seeking theiragreement to participate;
• deciding the roles of the various partnersin each of the agreed actions (see Table3.1);
• developing a management structure tocoordinate implementation of thestrategy.
Activity Possible partnersAssessment • NMCP/MoH – collecting information on malaria
epidemiology and population factors.• Social research organizations – designing community
research.• Commercial research organizations – designing and
conducting market research.
Sourcing and procurement • Organizations already procuring nets and/or insecticide.• Organizations with tax-free status, such as donor and UN
agencies, particularly if “pump-priming” is the strategyadopted.
• The commercial sector (wholesalers and retailers).
Monitoring and evaluation • NMCP/MoH, NGOs, market research organizations –monitoring.
• Local universities, local research agencies, internationalagencies – evaluation.
Storage and distribution • NMCP/MoH, hospitals, wholesalers – storage.• Medical supplies distributors, NGOs, the commercial
sector (manufacturers, wholesalers, retailers) –distribution.
Demand creation and promotion • Television and radio, print media.• Advertising agencies.• Social marketing NGOs.• Community drama groups.• MoH health educators.
Training • MoH, universities, NGOs.
Research • Local universities, local research agencies, internationalresearch organizations.
Table 3.1 Potential roles and responsibilities of different partners
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3.1.2 Developing a framework
ITN programmes or interventions shouldbe planned to fit within the national strategy.Planning involves defining more specificallywhat needs to be achieved and how it will be achieved. A logical framework is a useful tool in this planning process. Itidentifies the goal, purpose, outputs andactivities of a programme, the indicatorsthat will be used for monitoring andevaluation, and how these indicators willbe measured.
The goal is the overall objective that theprogramme or intervention will contributetowards. For example, the goal of mostnational ITN strategies and of most ITNprogrammes is to reduce morbidity andmortality due to malaria in the population,particularly in children under five andpregnant women. The purpose is thespecific objective of the programme. It is the effect that the programme isintended to achieve. For example, thepurpose of many ITN programmes isto increase household ITN coverage inspecific target groups. The outputs arethe direct products of the programmeactivities. The outputs should lead orcontribute to the purpose of the programme.
Figure 9 Developing a project framework, comprising purpose, outputs and activities
Assessment Strategy
Goal The health impact towhich the programmeaims to contribute
Purpose The main objective of the programme, which is achievable by theprogramme
Outputs The direct products of the programme, whichlead to achievement ofthe purpose
Activities The interventions of theprogramme, which leadto achievement of theoutputs
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The activities are the specific tasks that theprogramme will undertake. The outputsand activities will depend on the purpose of the programme.
Table 3.7 provides an example of a logicalframework for a social marketing strategy.Examples of indicators are included insection 3.2 on monitoring and evaluation.
3.1.3 Staffing, training, and supervision
Once it has been decided what theprogramme or intervention will do,an assessment of what staffing, trainingand supervision is required for eachactivity should be made.
3.1.4 Budgeting and funding
The next step in planning is to developa budget. It is important to ensure that allactivities are budgeted for. Then it will benecessary to assess whether or not thefunding available is sufficient to coverthe budget required for the programme orinterventions. If additional funding isrequired, decisions will need to be madeabout how this will be obtained, includingseeking support from donors.
The following questions should be used to help todecide about staffing, training and supervision needs: ◆ How many staff are required to carry out all the
proposed activities?◆ How many staff are available for these activities
in the different partner organizations?◆ Will additional staff be required? By what
organizations? ◆ How many new staff will be needed? What type
of skills will they need?◆ What training will need to be carried out? What
cadres of staff need training? How many staffrequire training?
◆ What supervision is needed? For whom? By whom?
◆ How will supervision be carried out?
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3.1.5 Planning monitoring
and evaluation
Once the monitoring and evaluationindicators and methods for measuringthese indicators have been decided, usingsection 3.2, a monitoring and evaluationplan should be developed. The plan shouldinclude the timeframe for carrying outactivities, with clearly defined roles andresponsibilities for data collection, collationand analysis. It should also specify who willbe responsible for supervising monitoringand for ensuring that findings are used tomodify programme design. The frameworkin Table 3.2 can be adapted to developa monitoring and evaluation plan.
Indicator Method Frequency Responsible of measurement and timing person
of measurement
Goal
Purpose
Output
1.
2.
3.
4.
Activity
1.
2.
3.
4.
5.
6.
7.
8.
9.
Table 3.2 Framework for a monitoring and evaluation plan
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3.2 Monitoring and evaluation
The framework for monitoring and evaluationoutlined in this section could be applied toany ITN programme. The role of the NMCPin specific monitoring and evaluationactivities will depend on the nationalstrategy and the extent to which the NMCPis involved in implementation of specificITN activities. But all NMCPs, regardless of the extent of their involvement inimplementation, are responsible formonitoring and evaluating changes inmalaria mortality and morbidity at nationallevel.
The main issues to consider in planningmonitoring and evaluation are:• indicators for monitoring and evaluation;• methods for measuring indicators.
The following questions should be used to helpwith planning for monitoring and evaluation:◆ What indicators will be used for monitoring
and evaluation?◆ What information will need to be collected
to measure the indicators?◆ Is any of this information being collected
already?
MONITORING AND EVALUATION
Monitoring is an ongoing process. Thepurpose of monitoring is to assess whetherprogramme activities are keeping on trackand whether changes are taking place.Monitoring can be continuous or periodic.The most important aspect of monitoring is analysing data collected and using thefindings to modify activities as necessary.
Evaluation is an overview of a programme up to a certain point in time. The purpose ofevaluation is to assess whether the activitiesare achieving or have achieved the outputsand whether these outputs are likely toachieve or have achieved the purpose.Evaluations are normally carried out duringand at the end of programme implementation.Mid-term evaluations can help to identifyproblems that may prevent a programmeachieving its purpose, so that changes can be made to activities and outputs. End ofprogramme evaluations can assess overallsuccess and summarize the lessons learned.
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◆ What tools will be used to measure the indicators?
◆ Who will collect and collate the information?◆ What training and supervision is required?◆ How often will monitoring information be
collected and analysed?◆ How will the findings be used to modify planned
activities? ◆ When will the programme be evaluated?
Who will do the evaluating?
3.2.1 Indicators for monitoring
and evaluation
As discussed above, the indicators usedfor monitoring and evaluation should relateto the programme’s goal, purpose, outputsand activities.
• Impact indicators
The goal of most ITN programmes is toreduce mortality and morbidity due tomalaria, usually by a specific amount. For example, the goal of RBM in Africa is toreduce malaria mortality and morbidity by50% by the year 2010. Examples of impactindicators, adapted from RBM, are shownin Table 3.3.
The results of field trials have shown thatITNs, if used correctly and consistently, willhave an impact on mortality and morbiditydue to malaria. For a range of reasons,however, it is difficult to assess the specificcontribution of ITN programmes to anyreduction in malaria mortality and morbidity.In many countries, populations with thehighest burden of malaria disease may nothave access to health facilities. In areaswhere populations do have access tohealth facilities, people may not use thesefacilities.
Reduction in mortality • Under 5 Crude Death Rate• Under 5 Malaria Mortality Rate• Under 5 Case Fatality Rate for severe
malaria in children admitted tohospitals and health centres withinpatient facilities.
Reduction in morbidity • Under 5 morbidity attributed to malaria(severe and uncomplicated)
• Anaemia in pregnant women20
• Low-birth-weight babies.20
Table 3.3 Impact indicators
20 These indicators were found useful in recent trials.
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Self-treatment with anti-malarialspurchased from pharmacies and shops is often the most common response touncomplicated malaria. This makes itdifficult to obtain an accurate picture ofmalaria mortality and morbidity. In addition,data collection at hospitals and clinics maybe erratic or unreliable and may not bebased on a definitive diagnosis of malaria(see Box 3). The catchment areas for an ITNprogramme and for health facilities mayalso be different, so data about malariamorbidity and mortality cannot be directlyrelated to the programme. Finally, it is alsodifficult to control for confounding factors,such as changes in transmission levels orimprovements in other health interventions,and for other malaria control interventions,which also impact on malaria morbidityand mortality.
Box 3 – Malaria morbidity and mortality: standardized case definitions for surveillance
Definitions of malaria morbidity and mortality vary, depending upon diagnosticcapabilities at different levels of the health system. Whenever possible,malaria case data should be reported by patient age group and parasitespecies. The following standardized case definitions should be used: In areas without access to laboratory-based diagnosis• Case of probable uncomplicated malaria – a patient with signs and/or
symptoms of uncomplicated malaria, who receives anti-malarialtreatment.
• Case of probable severe malaria – a patient requiring hospitalizationfor signs and/or symptoms of severe malaria, who receives anti-malarial treatment.
• Probable malaria death – death of a patient who has been diagnosedwith probable severe malaria.
In areas with access to laboratory-based diagnosis• Asymptomatic malaria – laboratory confirmation (by microscopy or
immuno-diagnostic test) of parasitaemia in a person with no recenthistory of signs and/or symptoms of malaria.
• Case of confirmed uncomplicated malaria – a patient with signs and/orsymptoms of uncomplicated malaria, who receives anti-malarialtreatment, with laboratory confirmation of diagnosis.
• Case of confirmed severe malaria – a person requiring hospitalizationfor signs and/or symptoms of severe malaria, who receives anti-malarial treatment, with laboratory confirmation of diagnosis.
• Confirmed malaria death – death of a patient who has been diagnosedwith severe malaria, with laboratory confirmation of diagnosis.
Source: RBM framework for monitoring progress and evaluating outcomes and impact. Geneva, WorldHealth Organization, 2000 (unpublished document WHO/CDS/RBM/2000.25; available on request fromCommunicable Diseases (CDS) Information Resource Centre, World Health Organization, 1211 Geneva 27,Switzerland).
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• Purpose indicators
The purpose of an ITN programme willdepend on the chosen strategy (seeChapter 1) and, in turn, the indicators usedfor monitoring and evaluation will dependon the purpose (see Table 3.4).
If, for example, the purpose is to increasecoverage among the general population oramong specific target groups, the indicatorused to measure achievement of thepurpose will be the percentage of coverageamong households or among the specifictarget groups.
Coverage can be reported in a numberof different ways including:• percentage of households with one or
more nets;• number of nets per net-owning
household;• percentage of under fives sleeping under
a net;• percentage of under fives sleeping under
a net in net-owning households;• percentage of pregnant women sleeping
under a net;• coverage per capita.
Monitoring tool for district health management teamMosquito net coverage
Project Name: Fictitia Mosquito Net Programme
District: Fictitia
Period: January 2000 to December 2000
ITN = Insecticide-treated mosquito net, HH = Household
Data to be taken from register of mosquito net sales and (re)treatment
Name ofvillage
Totalpopulation
Totalnumber of
HH
Total ITNssold
HH with atleast one
ITN
% HH withITNs
%populationwith ITNs
1 Narambu
2 Bykula
3 Stona
4 Chachay
5 Raulau
etc.
Total
Figure 10 A sample tool for monitoring net coverage. Measuring householdcoverage of ITNs is an important indicator in Roll Back Malaria.
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The most frequently used indicator ofcoverage is percentage of households withone or more nets. The choice of indicatorwill depend on the groups being targeted.In areas of high endemicity, these will beunder fives and pregnant women, but inareas of unstable malaria, where all agesare at risk, the target population may bedifferent. The same definition of coverageshould be used in baseline surveys andpost-programme evaluation. As well ascoverage, re-treatment and appropriateuse, all programmes should monitor andevaluate access and affordability in orderto assess equity.
Strategy Purpose indicatorsDemand creation • % household coverage with nets
• % nets re-treated with insecticide• % households using nets appropriately• % of pregnant women using a treated net
Sustained subsidies for equity • % coverage in households with target or vulnerable groups• % of households with target or vulnerable groups using
nets appropriately
Revolving fund • % household coverage with nets• % nets re-treated with insecticide• % households using nets appropriately
Social marketing • % household coverage with nets• % nets re-treated with insecticide• % households using nets appropriately
‘Pump-priming’ • % of sales of nets and insecticides in the commercialmarket
Emergency relief • % household coverage with nets in target population• % nets re-treated with insecticide in target population• % households using nets appropriately
Table 3.4 Purpose indicators
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• Output indicators
There is likely to be more variation inoutputs and indicators to measure theseoutputs between programmes than at thepurpose or goal levels. The outputs andindicators used to monitor and evaluateoutputs will depend on the chosen strategy.Table 3.5 includes the output indicators thatare considered to be essential for measuringthe operational success of each strategy,and the way in which these indicators canbe measured.
Defining cost per net delivered
Like coverage, cost per net delivered can bereported in different ways, including:
• Gross cost per net delivered – Where the grossprogramme cost is divided by the number of netsdelivered to give the gross cost per net delivered.
• Adjusted cost per net delivered – Where programmesare involved in other activities, such as promotion,the costs for these other activities and a proportionof overall running costs are subtracted from thegross programme costs. The adjusted programmecost is divided by the number of nets delivered to give the adjusted cost per net delivered. Thisfigure will depend on what proportion of theoverall costs is attributed to net distribution and what proportion to other activities.
Demand creation • % commercial sales volumes • Retail records
Sustained subsidiesfor equity
Revolving fund
• Effectiveness of targeting (leakageto non-target groups)
• Cost per net delivered to targetgroup
• Household survey among targetgroups
• Sales records• Financial accounts
• Programme sales volumes• Financial viability (independence
from subsidy)• Cost per net delivered
• Sales records• Financial accounts• Sales revenue in the revolving fund• Financial accounts
Social marketing • Programme sales volumes• Commercial sales volumes• Cost per net delivered• “Crowding-in” (increase in non-
programme net sales in thecommercial market) versus“crowding-out” (decrease in non-programme net sales in thecommercial market)
• Programme sales monitoring• Retail records• Financial accounts• Programme sales monitoring• Retail sales records
‘Pump-priming’ • Number of nets and quantity ofinsecticide sold
• Retail sales records
Emergency relief • Number of ITNs delivered • Programme records
Strategy Output indicators Means of verification
Table 3.5 Output indicators
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Programmes are likely to have severaloutputs, for which additional indicators andmeans of verification may be needed. Forexample, an output might be an increase in the proportion of the population or targetgroup who know about ITNs or who knowwhere to obtain an ITN, both of whichcould be measured using a KAP survey.Another possible output might be anincrease in the proportion of the populationor target group that can access nets andre-treatment within a reasonable distance,which could be measured by a retailoutlet survey.
The most important outputs and activities tomonitor include:
• sales of nets and insecticide by the programmeand by the commercial market;
• changes in knowledge about malaria and itstransmission;
• changes in knowledge about the use of ITNs to prevent malaria;
• changes in the use of ITNs.
• Activity (process) indicators
Process indicators are usually used tomonitor the performance of programmeactivities. As for purpose and outputs, theactivities will be determined by the chosenstrategy. If, for example, the strategy usedis demand creation using radio spots, atthe purpose level an indicator could be anincrease in the proportion of the populationwith knowledge of ITNs; at the output levelthe related indicator could be the proportionof the population listening to radio messagesabout ITNs; and at the activity level theprocess indicators could include thenumber of radio messages developed andthe frequency of play of radio messages.
3.2.2 Methods for measuring indicators
As well as developing indicators to monitorand evaluate the programme’s goal,purpose, outputs and activities, decisionsshould be made about how the informationwill be collected in order to enablemeasurement of these indicators. Pre-tested tools should be used for collectingdata. If new survey tools or monitoringforms are developed, they should be field-tested before use. Each indicator should beconsidered separately and the appropriatesampling scheme selected. For example,for indicators such as household coverage
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as wide an area as possible should besampled as there may be outlying areas ofvery high or very low coverage that wouldotherwise be missed. For other indicatorsit may be more appropriate to use more in-depth tools and techniques with a smallersample in a few sentinel areas.
• Measuring impact indicators
As discussed earlier, it is the role of theNMCP to assess reduction in morbidity andmortality due to malaria. The main tools forcollecting data related to impact indicatorsare:• health information systems,• health facility surveys,• demographic surveillance systems,
and demographic and health surveys.
Health facility surveys lead to biasedsampling, again because they only provideinformation related to those who attendthe facility. Unless the indicator is specificallyrelated to events within facilities, it isrecommended that health facility assessmentof malaria morbidity and mortality shouldbe accompanied by a community survey.
Under 5* CrudeDeath Rate
Numerator: Number of deaths ofchildren under 5 per yearDenominator: Mid-year population of children under 5 in the same year
Routine: HISSpecial surveys: DSS (INDEPTH),DHS, Health facility surveys,Community surveys
Under 5 MalariaMortality Rate
Under 5 CaseFatality Rate forsevere malaria inchildren admitted tohospitals and healthcentres withinpatient facilities
Numerator: Number of deaths inchildren under 5 attributed to malariaper yearDenominator: Mid-year population of children under 5 in the same year
Routine: HISSpecial surveys: DSS (INDEPTH),DHS, Health facility surveys,Community surveys
Numerator: Number of deathsattributed to severe malaria inchildren under 5 admitted asinpatientsDenominator: Total number of severemalaria cases in children under 5admitted as inpatients in the sametime period
Routine: HISSpecial surveys: Health facilitysurveys (inpatient surveillance)
Under 5 morbidityattributed to malaria(severe anduncomplicated)
Numerator: Number of malaria cases(severe/uncomplicated) in childrenunder 5Denominator: Mid-year population of children under 5 in the same yearORNumerator: Number of malaria cases(severe/uncomplicated) in childrenunder 5 seen/admitted in healthfacilityDenominator: Total number ofchildren under 5 seen/admitted in thehealth facility in the same time period
Routine: HISSpecial surveys: Community surveys
Routine: HISSpecial surveys:Health facility survey
Indicator Operational definition Data collection tool
Table 3.6 Data collection tools for impact indicators
* Indicators, numerators and denominator can also apply to other target or vulnerable groups.
Source: Roll Back Malaria Initiative in the African Region Monitoring and Evaluation Guidelines Draft Harare, 2000; RBM framework for monitoring progress and evaluating outcomes and impact. Geneva, World Health Organization, 2000(unpublished document WHO/CDS/RBM/2000.25; available on request from Communicable Diseases (CDS) InformationResource Centre, World Health Organization, 1211 Geneva 27, Switzerland).
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Demographic Surveillance Systems (DSS),using sentinel sites to monitor trends inmorbidity and mortality, are operating in28 sites in 14 African countries. The DSSnetwork is currently being strengthened to include surveillance of malaria mortalityin these sites, and to use a standardizedmethodology. Demographic and Health
Surveys (DHS), funded by USAID andimplemented by Macro International Inc.,have been extended to include a malariamodule. This will allow community-basedcollection of information related to severalRBM indicators and to ITNs. For countrieswithout DSS sites, the WHO RegionalOffice for Africa (AFRO) has developeda modified DHS survey tool, which willprovide information that can be usedto calculate under five and infantmortality rates.
Ideally, the routine Health Information
System (HIS) should be used to monitorand evaluate the impact of malaria controlinterventions. In many countries, however,there are problems with the quality orcoverage of data collected through the HIS.As discussed earlier, health facility dataunderestimate malaria morbidity andmortality, because many people do nothave access to or do not use healthfacilities.
Practical tips◆ Keep data collection to a minimum, especially
at community level, and use existing systemswhere possible. Collecting too much informationis a waste of time, and long complicated formswill cause confusion and result in inaccuratereports or absence of reports. They can alsocause difficulties in data collation.
◆ Start collecting data as early as possible inthe programme, to identify any problems soonerrather than later.
• Measuring purpose indicators
The main tools for collecting data relatedto indicators at purpose level (which mainlyconcerns coverage) are:• community and household surveys• demographic and health surveys.
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Community and household surveys can bedesigned to assess coverage of nets andfrequency of insecticide treatment only, orto also assess changes in KAP. The scopewill depend on the purpose of theprogramme and the resources available.Because community and householdsurveys are expensive and time-consumingto carry out, they are usually only conductedon a periodic basis and in a limited numberof sites. Careful selection of survey sites is therefore very important, and factors to consider when choosing sites includedifferences between urban and rural areas,proximity to breeding sites and density ofmosquitoes (both nuisance biters andAnopheles). AFRO has developed samplingguidelines for community surveys of ITNcoverage and use (see Box 3.1).
The malaria module included in some of the most recent demographic healthsurveys in Guinea, Malawi, Rwanda andUganda will provide information about net coverage on a larger scale.
• Measuring output
and activity indicators
It should be possible to monitor andevaluate outputs using information that iscollected to monitor and evaluate activities.
Figure 11 Focus group discussions can help to assesschanges in perceptions about nets
Source: Mehra S. Partnerships for change and communication: guidelines for malaria control.WHO/Malaria Consortium, 1997. Illustration: J Mehra
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The level of programme sales of nets andinsecticides should be carefully monitored.If, for example, sales are low, then thereasons can be investigated and stepstaken to overcome problems with supply ordemand. Evaluation of programme sales isalso an important measure of operationalsuccess. Methods for monitoring andevaluating programme sales includeprogramme sales records and financialaccounts.
It is also important to monitor the effects of programmes on commercial sales ofnets (and to a lesser extent insecticides),especially where strategies of demandcreation, social marketing, and “pump-priming” are used. Methods for monitoringcommercial sales include surveys of retailoutlets. To date, however, few programmeshave carried out this type of monitoringand evaluation.
Evaluation of the supply side (e.g. retailaudits) should be undertaken separatelyfrom evaluation of the demand side (e.g.household surveys), since they measuredifferent types of things among differentsamples, but the evaluations should becoordinated.
Box 3.1 – AFRO sampling guidelines
Sample size
At least 25–30 households and at least 30 children underfive and 25 pregnant women (or other target groups) percommunity.
Sampling method
Randomly choose a direction by spinning a bottle on theground at the centre of the community. Proceed in thedirection that the bottle is pointing, until you have covered10 households in your survey. If houses are not in anexact line, follow the approximate direction. If you reachthe end of the community before identifying 10 households,go back to the starting point and choose a new direction.If several families live in a house, only interview one family.
Source: RBM initiative in the African region: monitoring and evaluation guidelines(draft). Harare, 2000.
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GoalReduce the incidence of malaria and consequent illness and death.
PurposeTo develop feasible, sustainable and tested strategies for increasingavailability, ownership and usage ofmosquito nets and insecticide for nettreatment, suitable for large-scaleapplication.
1. Strategies tested in the projectsuccessfully adopted in larger-scale intervention elsewhere.
2. Improvements in access to and use of nets and insecticide.
3. Evidence on the appropriateness of strategies is documented.
1. Proposals, reports and publicationsfrom other projects.
2. Coverage surveys; consumptionrecords.
3. Monitoring and evaluation reports,workshops, scientific publications.
An adequate and informative range of strategies is tested; the monitoringprocess is adequate, at least some of the strategies prove to be feasible,and those which prove to besustainable in the medium termcontinue to be so over longer periods.
Outputs1. Increased demand for nets; and
net use regarded as the norm notthe exception.
2. Effective insecticide distributionsystems, including DIY kits, fixedand mobile net-treatment centresand treatment agents established.
3. Increased knowledge of anddemand for insecticide by netowners.
4. Improved access in rural areas to commercially available nets and insecticide.
5. Increased access to nets byvulnerable groups (children,pregnant mothers, poor families)through effective and efficient use of subsidies.
1.1 Increased sales and use of project nets.
1.2 Increased sales and use of commercial nets.
1.3 Increased % households with at least one ITN.
2.1 Use rates of insecticide. 2.2 Users’ awareness of the price
of net-treatment, and theirperceptions of availability.
3. Increased sales and use.4. Number of commercial outlets
and turnover in rural areas.5. Surveys of fate of nets distributed
at subsidized prices.
1. KAP surveys. Focus groups, retailsurveys of availability. Projectreports, social and economicevaluation reports.
2. Informal interviews, focus groups,exit surveys, sales.
3. KAP surveys. Focus groups, retailsurveys of availability. Project andconsultants’ reports, sales reports.
4. KAP surveys. Focus groups, retailsurveys of availability. Projectreports, social and economicevaluation reports.
5. Project reports, social andeconomic evaluation reports.
1. General economic decline couldreverse current increasing trend in demand.
2. Net users prove willing to pay for net treatment in one form oranother.
3. Demand is not reduced by fears and rumours of insecticide toxicity.
4. General economic decline couldreverse current increasing trend in demand.
5. Methods of preventing “leakage”of subsidized nets may fail.
Project structure Indicators of achievement How quantified and assessed Assumptions
Table 3.7 Example of a logical framework for a social marketing strategy21
21 Adapted from PSI Social marketing of mosquito nets and insecticide for net treatment project in the United Republic of Tanzania
Sourcing andprocurement
Chapter 4
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If ready-made nets are available
locally at a price that most people can
afford, sourcing and procurement of
nets may not be necessary, unless it is
intended to target vulnerable groups
that are not reached by existing
systems.
If the national strategy includes provisionof nets and insecticide, decisions aboutsourcing and procurement of these
commodities will need to be made. For thepurposes of procurement, it is important toconsider nets and insecticide as separatecommodities.
This chapter provides an overview ofsourcing and procurement issues. It covers:• nets,
• insecticide,
• ordering systems.
Sourcing and procurement
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4.1 Nets
The main factors to consider are:• types of nets,• quantity of nets,• sources of nets.
The following questions should be used to help tomake decisions about sourcing and procurement ofnets:◆ What type of nets are people already using?
(see Chapter 2)◆ What type of nets would people prefer to use?
(see Chapter 2)◆ Will you make more than one type of net available?◆ How many nets will be required to cover the target
population or group?◆ What sources of nets exist?◆ From which of these sources nets be procured?
4.1.1 Types of nets
Types of nets vary in terms of fabric, shapeand design, size and colour. It should bedecided what type of net will be mostappropriate for the target population.
Fabrics commonly used for ITNs includepolyester, cotton, cotton-synthetic blends,nylon, polyethylene and polypropylene.These fabrics, which are made into nettingor sheeting, vary in absorbency. Polyester isthe most popular fabric in many countries,because it is lighter than cotton and absorbsless liquid. Fabrics that absorb less liquidare easier to wring out and reduce the wasteof excess insecticide, although heavier, moreabsorbent fabrics can be left to drip ontoplastic sheeting and the excess insecticidereused.
Netting is generally more popular thansheeting, because it is lighter, absorbs less liquid and allows more air movement,although it provides less privacy than cottonsheeting. Most larger ITN programmes use netting produced by commercialmanufacturers. Sheeting is more likely tobe made by local entrepreneurs and usedby small projects.
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Different fabrics also vary in strength, meshsize, and flammability. Fabric strength ismeasured in denier: the higher the number,the stronger the fabric. Fabrics of between70 and 100 denier are adequate for nettingmaterial, but fabrics of less than 70 denierare less suitable because they tear easily and do not last long. Mesh size is measuredas the number of holes per square inch: the smaller the number, the larger the hole.Standard mesh sizes for netting are 156 and196, and both sizes prevent mosquitoes fromentering. A mesh size of 156 allows betterventilation because it has larger holes, butmore care is needed to ensure that nettingwith larger holes is treated properly withinsecticide. Cotton nets are more flammablethan polyester nets, but polyester netsare more dangerous if they catch fire,because they melt causing severe burnson the skin.
The quality of fabric used to make netsvaries. It should be decided whether tostandardize quality or to make available nets of different quality for different targetgroups. Standardizing the quality of fabric makes it possible to standardize theinsecticide treatment dose. While mostpeople will generally pay a higher price forbetter quality, however, the poorest may notbe able to afford to buy better quality nets.
Pre-treated and long-lasting nets
• Non-long lasting nets and factory pre-treated netsare available but, at present, their use is onlyrecommended for emergencies. In all othercircumstances, untreated nets and insecticideshould be procured and distributed separately,because of the need to increase understanding ofthe importance of insecticide treatment.
• Some commercial manufacturers are developing“long-lasting treated” nets where the insecticideremains effective for the life of the net, even afterregular washing. This would end the need for net re-treatment with insecticide, reduce insecticideconsumption, and potentially increase ITN coverage.However, it is not yet clear how long these netsremain effective under normal day-to-day conditions.
Shape and design of nets vary considerably.The most common shapes are conical(round) and rectangular. Some nets have aborder on the hem or skirt. A border makes a net stronger and more durable, but itincreases the cost and can also increase theamount of insecticide absorbed. Conical netsare easier to hang up and take down thanrectangular nets, take up less space and areuseful in smaller houses. But conical nets areusually more expensive, the wire hoop usedto hang the net must be removed before
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washing, and their smaller size means thatthere is more chance of being bitten whentouching the sides of the net during sleep,unless the net is treated with insecticide.Rectangular nets are lower priced and morespacious, but take up more room and areoften perceived to be more suitable forsleeping mats than beds.
Size of net required depends on the bed ormat size and the number of people who willsleep under it. Larger nets require morefabric and insecticide for treatment, whichincreases the cost, but larger nets also covermore people. It is important to choose a netthat is large enough to cover a typical bed ormat without needing to be pulled too tightly.If the net is too small, those sleeping under itare more likely to touch the sides and to bebitten. It is also important to measure bedand mat sizes and to compare these withnet sizes.
Do not rely on descriptions such as doubleor single, because sizes that fit thesedescriptions vary by country and manufacturer.
The most commonly available net colours
are white, green and blue. White nets getdirty quickly. They are likely to be washedmore frequently than darker coloured netsand, as a result, to require more frequentinsecticide treatment. Blue or green nets
Figure 12 Nets are available in a number of different shapes and sizes
Source: Chavasse D, Reed C, Attawell K. Insecticide-treated net projects: a handbook for managers.Malaria Consortium, 1999.
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are more practical in dusty or smokyenvironments.
In addition to technical issues, key questionsto consider when deciding about net type are:• What type of nets do people prefer?• Should more than one type of net be made
available?
The type of net or nets procured must meettechnical specifications. For example, netsmust be of an adequate size to provideprotection. It is equally important to procurenets of the size, shape and colour that peoplewant. The findings of the assessment of netuse and net preferences (see Chapter 2)should have identified what type of netspeople have now and what type they wouldlike to have. If most people would prefer touse the same type of net, then this is thetype that should be procured. If there is awide range of preferences, then the decisionabout what type of net or nets to procureshould also take into consideration otherissues, such as cost and availability.
4.1.2 Quantity of nets
The size and sleeping habits of the targetpopulation (see Box 4) will determine thenumber of nets required.
The size of the target population will dependon whether it is intended to cover the wholepopulation or specific population groups,for example, children under five, pregnantwomen, the poorest socioeconomic groups,or non-immune populations. Use thepopulation data obtained during theassessment (see Chapter 2).
Sleeping habits as well as family size willdetermine how many nets are required tocover everyone in a household or the mostvulnerable in a household. For example,in some cultures mothers sleep with theiryoung children so one net may be sufficientto cover vulnerable groups, but in otherswhere they sleep separately more than onenet will be needed. Use the informationobtained during the assessment (seeChapter 2) about the sleeping habits of thepopulation and of any specific target groups,such as under fives or pregnant women.
The quantity of nets needed also depends on whether or not nets will be sold to bothtarget and non-target groups or to the targetgroup only. If nets are only sold to the targetpopulation there is likely to be some leakage
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of nets to those outside the target population,so it will be necessary to procure more thanthe number of nets required to cover thetarget population.
4.1.3 Sources of nets
Potential sources of nets include localcommercial manufacturers of ready-madenets, small-scale producers of nets, such aslocal tailors, and commercial manufacturersof ready-made nets and netting outside thecountry. The most appropriate choice willdepend on the sources available and thetype and quantity of nets required.
Procurement of ready-made nets fromin-country manufacturers is simpler and less time-consuming than importing nets or netting, and also supports the nationaleconomy. If ready-made nets aremanufactured in-country, but are not beingmarketed effectively, consideration could begiven either to promotional activities tocreate demand and negotiation with privatesector distributors and outlets to market the nets, or to promotional activities tocreate demand together with short-termprocurement and distribution of nets topump-prime the market. If ready-made netsmanufactured in-country are not the typethat people prefer, the findings about netpreferences could be shared with the
Box 4 – Calculating the number or standing crop of nets needed
When the size of the target population has been estimated,calculate the number or “standing crop” of nets needed to coverthe target population per year. This is particularly important forlonger-term interventions, because nets only last for a maximumof about 5 years and, after this time, they will need replacing. To calculate the standing crop, determine the size of the targetpopulation, the average lifetime of a net, and the average numberof the target population sleeping under each net.
Example 1. If the target population is 10 000; the average lifetimeof a net is assumed to be 5 years, and an average of 2 people arecovered by each net: the number of nets needed to cover thetarget population is 10 000 / 2 = 5 000. The lifetime of a net is5 years, so1 000 (5 000 / 5) nets are needed each year to coverthe target population.
Example 2. If the total population is 10 000; the target populationis pregnant women, who represent 5.5% of the total population;and the average lifetime of a net is assumed to be 5 years: at anyone time there will be 10 000 x (5.5 / 100) = 550 pregnant women.550 nets will be needed, assuming 1 net per pregnant woman. The lifetime of a net is 5 years, so 110 (550 / 5) nets are neededeach year to cover the target population.
Note: These calculations assume initial net coverage is nil.
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manufacturers. The feasibility and costof producing nets that meet people’spreferences could likewise be explored with the manufacturers.
In some communities, there may be localtailors producing nets on a small scale.Some projects have provided netting,training and equipment for local tailors to sew nets, to increase net availability and generate income. This approach isunlikely to be appropriate for larger scaleinterventions where rapid coverage of largepopulations is the objective. In addition,locally tailored nets may be both moreexpensive and of poorer quality thancommercially manufactured nets.
Small-scale tailoring of nets may, however,be appropriate where there is demand fora wide range of net types or where netcoverage is already high.
Importing nets or netting may be the onlyoption if nets are not manufactured in-country, or if locally manufactured nets aretoo expensive or do not meet specificationsor are not made in sufficient quantities tomeet demand. (The PATH Canada directoryof insecticides and mosquito nets for sub-Saharan Africa22 provides information aboutinternational net manufacturers.)
Importation of nets, however, can bea lengthy process, and adequate lead-timeshould be allowed between ordering anddelivery to ensure that nets are available to meet the demand created. It may beworthwhile investigating whether otherorganizations are willing to act asprocurement agents or whether there isthe potential for partnerships that wouldenable nets to be procured at lower prices.
In addition, the cost of imported nets andnetting may be increased by governmenttaxes and tariffs, which are intended togenerate revenue, protect domesticproducers and encourage economic self-reliance. Tariffs are imposed on foreign-produced goods, for example in the form
22 Obtainable from: PATH Canada, 1 Nicholas Street, Suite 1105Ottawa, Ontario, Canada KIN 7B7 E-mail: [email protected] – Internet: http://www.pathcanada.org
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of import duty, fiscal duty, import tax and customs duty. Taxes are domesticconsumption charges, for example in theform of sales tax, excise tax, turnover taxand value added tax. At the 2000 AbujaSummit, African leaders pledged to removetaxes and tariffs on nets and insecticidesused to treat nets amongst others.
International agencies and NGOs areexempted from taxes on imported goods,which allows them to import nets andnetting at low prices and to sell nets at lowerprices than the local private sector. There istherefore a danger that importing nets andnetting will limit the development of thecommercial market, and importing as a short-term option should only beconsidered until increased demandstimulates the development of viablein-country commercial manufacture.
4.2 Insecticides
The main factors to consider are:• type of insecticides• insecticide formulations• packaging and labelling• quantity of insecticide• sources of insecticide• safety• efficacy monitoring
The following questions should be used to help todecide about insecticide procurement and sourcing:◆ What type of insecticide should be used?◆ What is the most appropriate formulation
of insecticide?◆ What form of packaging should be used?◆ What sources of insecticide exist? From which
sources will insecticide be procured?◆ What safety and efficacy monitoring measures
will need to put in place?
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4.2.1 Type of insecticide
The insecticides recommended for treatingmosquito nets are permethrin, etofenprox,and the alphacyano pyrethroids: deltamethrin,lambdacyhalothrin, cyfluthrin and alpha-cypermethrin. These insecticides adhere to all types of fabrics and are effective evenin small amounts. Permethrin was the firstinsecticide to be recommended by WHO fortreating nets, and there is more experiencewith use of permethrin than with otherinsecticides. Both permethrin and thealphacyano pyrethroids are more insecticidalwhen used on synthetic fibres than on cotton,so cotton nets need to be treated with higherdoses to achieve equivalent insecticidal effect.
The alphacyano pyrethroids are more toxicto insects so they can be used at much lowerdosages (15–50mg/m2) than permethrin(250–500mg/m2). The recommended dosesfor treating mosquito nets with commonlyused insecticides are given in Table 4.1.
Permethrin will remain effective on a net forapproximately 6 months if it is not washed.Washing a permethrin-treated net once willreduce the effectiveness of the insecticideby at least 50%. Alphacyano pyrethroids willremain effective for approximately 6–12months, even after one or two washings.Alphacyano pyrethroids are more cost-
Insecticide Dose (mg/m2) Dose for one net* (15m2)
Deltamethrin (K-Otab) 25% WT23 25 1 tablet
Deltamethrin 1% SC24 25 40 ml
Lambdacyhalothrin 2.5% CS25 15 10 ml
Alphacypermethrin 10% SC 40 6 ml
Cyfluthrin 5% EW26 50 15 ml
Etofenprox 10% EW 200 30 ml
Permethrin 10% EC27 500 75 ml
Table 4.1 Insecticides recommended for net treatment
* In 0.5 litre of water for any synthetic net and 2 litres of water for any cotton net.
23 WT = Water dispersible tablet24 SC = Suspension concentrate25 CS = Capsule Suspension26 EW = Emulsion oil in Water27 EC = Emulsifiable Concentrate
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effective than permethrin, because a lowerdosage is required to treat a net and becauseof greater persistence. Alphacyanopyrethroids are also safer for use in homedipping than permethrin.
4.2.2 Insecticide formulations
The WHO Pesticide Evaluation Scheme(WHOPES) should approve insecticideformulations used for net treatment forpublic health use. WHOPES uses laboratoryand field evaluation to assess insecticidesafety, efficacy, ease of use, acceptability andcost-effectiveness. If an insecticide productmeets WHOPES standards, quality controland international trade specifications aredeveloped. (see: www.who.int/ctd/whopes)
Insecticides for use on nets are available as emulsifiable concentrates, capsulesuspensions, emulsion oil in water,suspension concentrates and waterdispersible tablets. These formulations are mixed with a suitable quantity of waterto make a solution that will treat a net withthe required dose of insecticide. Wettablepowder formulations, which have been used for spraying hard surfaces, are notrecommended for net treatment becausethe insecticidal activity wears off quickly.Similarly, agricultural formulations are not
recommended for use on mosquito nets asthe efficacy and safety of these formulationsof insecticides cannot be assured.
In Emulsifiable Concentrate (EC)
formulations, the insecticide is dissolved in a solvent to give a clear, often yellowishsolution that turns milky white when wateris added. The only insecticide that isrecommended in EC formulation ispermethrin. For home treatment of nets,only permethrin 10% EC formulation (witha childproof cap) is recommended, becauseof concerns about toxic side-effects fromskin contact or accidental swallowing. The solvents used in EC formulations havea strong odour, and can also have adverseeffects on users and on the environment.Agricultural EC formulations should not beused on nets, because some of theseinsecticides use very toxic solvents.
In Capsule Suspension (CS) formulations,the insecticide is encased in microscopicplastic capsules and suspended as anemulsion in water. CS formulations are lessodorous and last longer than EC formulations.Agricultural capsules should not be usedbecause they are not suitable for nettreatment.
In Emulsion oil in Water (EW) formulations,the insecticide is dissolved in synthetic oil
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mixed with water. The fine oil phase dropletsresult in a high level of adherence to netfibres. In Suspension Concentrate (SC)
formulations, the active ingredient is inthe form of crystalline particles mixed with a solvent. Only water-based SCs arerecommended for use on nets. In Water
dispersible Tablets (WT) formulations,the insecticide is mixed with an inert carrierand moulded into a tablet. A bitter tastingagent is added to discourage children fromswallowing the tablets. WT formulations areuseful for home net treatment.
4.2.3 Packaging and labelling
Packaging options include 1 litre andautodose bottles, and single treatmentsachets, vials and tablets. The mostappropriate type of packaging will dependon the approach to delivery and nettreatment (see Chapter 5). Individualtreatment of nets is recommended,regardless of whether treatment is doneat dipping centres, by mobile teams or at home. For this reason, large drums ofinsecticide are no longer recommended foruse in net treatment. Single dose treatmentsare more expensive because of the costsof packaging, but may be the method ofchoice for those who prefer to treat theirnets at home.
Insecticides usually come in three types ofbottles: 1 litre bottle, autodose bottle, andsingle treatment vials. The 1 litre bottle isuseful in outlets that offer routine treatmentand re-treatment services. The requiredamount of insecticide for the number of netsto be treated can be poured from the bottleinto a measuring cylinder.
Autodose squeeze-and-pour bottles are alsouseful for outlets that offer routine treatmentand re-treatment services, and for agentsoffering a door-to-door dipping service.An adaptation of 1 litre bottles, autodosebottles are easy to use because the bottlemeasures the correct amount of insecticidefor net treatment.
A small graduated chamber is connected tothe main bottle by a thin tube. Squeezing thebottle forces liquid up the tube and into thechamber. When the chamber is filled with theamount of insecticide needed to treat a net,the liquid can be emptied into a mixing bowl.
Home treatment kits remove the need forre-treatment by health workers or othertrained “dippers”. Home treatment usingsingle dose units, available through shops,kiosks, health facilities or other outlets, isbecoming more common in some countries,for example, Malawi and the United Republicof Tanzania. One of the advantages of home
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treatment kits is that they are in sealedpackages, so they are less liable toadulteration.
Single treatment vials are designed for theDIY home treatment market. They shouldhave a childproof cap and include clear,locally appropriate instructions about correctand safe use. Check the packaging of locallyproduced vials carefully, because sometypes of plastic absorb the active ingredientfrom the insecticide solution leaving anineffective dose.
Sachets are another form of packaging that are appropriate for single net treatment,and are also designed for the DIY hometreatment market. Again, appropriatepackaging is important, as insecticide maybe lost in the seals of foil laminated plasticsachets. Tablets are probably the easiestform of packaging for DIY home treatmentof single nets.
Net plus insecticide combination packs,that include an untreated net and a singledose of insecticide to treat the net, are alsobecoming available. This approach reinforcesthe idea of the need to treat the net andavoids the need to make two separatepurchases.
Clear labelling of insecticide is essential(see Box 4.1). In most countries there are
regulations about the minimum informationthat must be included on insecticide labelling.If the intervention involves repackaging,labelling of the repackaged insecticide mustconform to national and WHO regulations.
Instructions for use must also be clear,understandable and locally appropriate,whether kits, tablets, sachets or otherpackaging are produced locally orinternationally. Instructions for productsintended to be used for home treatmentshould be developed in-country with expertadvice. Negotiations with manufacturersshould ensure that locally developedinstructions are included rather thangeneric instructions.
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4.2.4 Quantity of insecticide
The quantity of insecticides required isdetermined by the amount needed for initial treatment of nets to cover the targetpopulation and the amount needed forregular re-treatment of these nets (see Box4.2). The frequency of re-treatment dependson the persistence of the insecticide usedand how often nets are washed.
4.2.5 Sources of insecticide
Potential sources of insecticide includecommercial manufacturers and supplierswithin and outside the country. The mostappropriate source will depend on the typeand quantity of the insecticides required. It is unlikely, however, that the range ofinsecticides, formulations and packagingdescribed above will be available in mostcountries.
Obtaining insecticide from in-country
manufacturers or suppliers is simpler and less time-consuming than importinginsecticide, because it is not necessary todeal with import or regulatory procedures. If the packaging of the insecticides availablein-country is not appropriate, for example ifkits for DIY home treatment are not available,
Box 4.1 – Labelling
• Generic name and/or brand name – generic names end in thrin
• Formulation – Emulsifiable Concentrate (EC), CapsuleSuspension (CS), Emulsion oil in Water (EW), SuspensionConcentrate (SC), Water dispersible Tablets (WT)
• Concentration – refers to the number of grams per 100 ml
• Safety instructions, warnings and symbols – toxic symbols,poison symbols
• Production date – insecticides should usually be usedwithin 2 years of manufacture
• Expiry date – the time when the insecticide will no longer beeffective
Box 4.2 – Calculating the amount of insecticide needed
Example 1. Where cyfluthrin 5% EW is the insecticide of choice;15ml of insecticide is needed to treat each net; the targetpopulation is 10 000; an average of 2 people sleep under eachnet; and the best re-treatment rate expected is 60%.
• 15 x (10 000 ∏ 2) = 75 000 ml (75 litres) of insecticide is neededto treat nets initially for the whole target population.
• If 60% of the target population re-treat their nets every6 months, then an additional 75 000 x 60% = 45 000 ml(45 litres) x 2/year = 90 000 ml (90 litres) of insecticidewill be required every year.
• The total amount of insecticide required is 165 litres.
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then repackaging could be considered as an option. Again, this should be negotiatedwith local manufacturers or suppliers, sincerepackaging is technically complex andshould ideally be undertaken by insecticidemanufacturers. Repackaging should only becarried out on licensed premises, which canensure that staff are adequately protectedagainst toxic hazards, that the resultingproduct will be properly packaged andlabelled, and that the content will conform to relevant quality standards.
Price is often a factor that limits insecticidetreatment and re-treatment of nets. It istherefore also important to negotiate thelowest price possible with manufacturers,suppliers and distributors, provided that thisdoes not compromise efficacy or safety.Packaging increases the cost of products forDIY home treatment of single nets, but lowerprices can often be negotiated for bulkpurchases.
If the insecticides recommended for treatingnets are not available, or are not available in appropriate formulations, it may benecessary to import. (The PATH Canadadirectory of insecticides and mosquito netsfor sub-Saharan Africa28 provides
information about international insecticidemanufacturers.) As with nets, taxes andtariffs are also a barrier to the importationof insecticides. The need for WHOPESapproval and in-country registration, inaddition to normal import procedures,makes importation a complicated andlengthy process. Importing should only be considered as a short-term option, and it is important to start negotiation as soon as possible with local manufacturers andsuppliers about the feasibility and costsof supplying suitable insecticide in theformulation and packaging required.
4.2.6 Safety
The active ingredient in insecticides, andthe solvents used in some insecticideformulations, can be toxic to humans andthe environment. Although there have beenno reports of deaths caused by pyrethroidinsecticides, it is important to take measuresto protect people from harmful effects. It is also important to dispose carefully of insecticide, to protect the environmentfrom harmful effects.
The risk of adverse side-effects depends on the toxicity of the insecticide and the way
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it is handled and used. Those dipping manynets sometimes experience transientsymptoms, such as paresthesia (abnormalnumbness or tingling). Dipping should beconducted in well-ventilated areas, ideallyoutside, to avoid the build-up of fumes.Protective clothing, including gloves andprotective glasses, should be worn, especiallyby those dipping large numbers of nets.After insecticide treatment, nets should beleft to dry properly before they are used. The risk of adverse side-effects in users of treated nets, however, is minimal.
It is important to avoid contaminating watersources with insecticide. Leftover dilutedinsecticide, and water in which treated netshave been washed, should be disposed of in a rubbish pit or a pit latrine. Treatednets should not be washed in small rivers,streams or ponds, to avoid contaminationof water sources and toxic effects on fishand crustaceans.
Figure 13 Washing nets in a bucket or bowl rather than a streamprevents insecticides contaminating water sources.Wring the net gently – if you wring too hard, you will losethe insecticide. Gloves should be worn when washing ortreating nets
Source: Chavasse D, Reed C, Attawell K. Insecticide-treated net projects: a handbook formanagers. Malaria Consortium, 1999.
28 Obtainable from: PATH Canada, 1 Nicholas Street, Suite 1105, Ottawa, Ontario, CanadaKIN 7B7. Email: [email protected]. Web site: http://www.pathcanada.org.
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The risk of poisoning if insecticide is swallowed depends uponthe formulation and concentration of the insecticide. Pyrethroidsare metabolized by the body, so the effects are acute rather thanchronic. The symptoms of poisoning include paresthesia,irritation of the upper respiratory tract, salivation and, occasionally,allergic reactions. If poisoning is suspected, follow Steps 1 to 3:
Step 1. Collect information
To assist a doctor or medical officer to provide appropriatetreatment, find out the following:
• name of the insecticide (keep the bottle or sachet to show the doctor) • route of exposure • amount consumed• time of poisoning • reason for poisoning • emergency information from the product labelling
Step 2. Give first aid
If the person is not breathing:
• give mouth-to-mouth resuscitation if required;• remove all vomit and saliva from the mouth;• place a handkerchief between the mouth of the patient and themouth of the person giving first aid, to protect the person givingfirst aid from the insecticide.
If the insecticide has contaminated the person’s skin:
• remove all contaminated clothing immediately;• wash affected areas with soap and large quantities of water.
If insecticide has been swallowed:
• give the person plenty of water to drink (avoid alcohol ormilk); if available, give a suspension of 10g of medicalcharcoal in 150– 200 ml of water;
• vomiting should only be induced by a qualified person (unlessthere is severe poisoning and no medical assistance isavailable) because there is a risk, associated with vomiting, of aspiration of the insecticide, which could cause pneumonia;
• vomiting should only be induced in a person who is fullyconscious, by stimulating the back of the throat with afingertip;
• give large quantities of water to drink after vomiting.If the insecticide has been splashed in the eyes:• gently open the eyelids with the fingers and flush with running
water for several minutes.If inhaled, remove victim from exposure and give supplementaloxygen if needed and available.Step 3. Take to a doctor
• For pyrethroid poisoning with prolonged paresthesia, applyvitamin E oil preparation to the affected skin.
• For irritation of the upper respiratory tract, relieve symptoms withinhalation of water vapour aerosol or cough-relieving medicine.
• If convulsions occur after severe poisoning, give an intravenousinjection of 5–10 mg diazepam or a benzodiazepine derivative.
• Corticosteroids should only be given in cases of definiteallergic symptoms.
Diagnosing and treating pyrethroid poisoning
Source: Chavasse D, Reed C, Attawell K. Insecticide-treated net projects: a handbook for managers. Malaria Consortium, 1999.
For further information on safety, see WHO Fact Sheet WHO/CDS/CPE/WHOPES/99.5. Safety of pyrethroid-treated mosquito nets.Available at: http://www.who.int/ctd/whopes/sptmn_eng.pdf
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4.2.7 Efficacy monitoring
It is important that the insecticide selectedfor use on nets achieves the desired effect.Efficacy may be reduced if an insecticideis sub-standard, expired, or has not beenstored properly. Incorrect treatment orexcessive net washing can also reduceinsecticide efficacy. Sometimes, mosquitoescan develop resistance to a particularinsecticide. For these reasons, it is essentialto monitor insecticide efficacy.
Insecticides should be quality controlled bythe manufacturer and by the national bodyresponsible for regulating insecticides withinthe country. If there is no in-country capacityfor monitoring the efficacy of insecticides,a regional body should be identified that canhelp to identify the reason or reasons forreduced effectiveness.
Troubleshooting
If there is an apparent reduction in insecticide efficacy:
1. Investigate operational factors. These could include: theinsecticide being used at the wrong dilution, insecticide beingused after its expiry date, unrealistic perceptions of insecticidalaction, excessive washing of the net, improper storage, incorrectdipping or treatment procedures resulting in under-dosing.
2. Contact the manufacturer. If there are no obviousoperational errors, contact the manufacturer with the batchnumber of the insecticide. The manufacturer should be able toreport on quality control performed on all batches of insecticide.
3. Contact WHO for advice. Contact WHO Geneva or the nearestWHO regional or country office. Bioassay kits for assessing theeffect of insecticides on nets, available from WHO, may not bepractical in some settings, but dosing kits, which are a morepromising option, are currently under development.
4. Insecticide resistance. Find out about insecticide resistance.The MOH or other bodies should be monitoring resistanceto pyrethroid insecticides in all areas where ITNs are used.Resistance is defined as when 20% or more of mosquitoessurvive exposure to insecticide at diagnostic concentrations,using the WHO susceptibility test kit and procedure. Once amosquito population is resistant to one pyrethroid, it is likelythat it will be resistant to all pyrethroids to some extent.
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Sour
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4.3 Ordering systems
Ordering can be done through a bulkpurchase, through a standing order, orthrough re-ordering at set time periods or inresponse to demand. The advantages anddisadvantages of these methods of orderingare summarized in Table 4.2. The approachto ordering will depend on the scope andtimeframe of the intervention.
If it is proposed to supply nets andinsecticide to a defined target populationfor a defined time period, once the quantityof nets needed to cover the target populationand to keep them covered and the quantityof insecticide needed to treat and re-treatthese nets has been calculated, it may bedecided to order the required quantities inbulk from the relevant manufacturersor suppliers.
If the intervention will continue for anindefinite time period and there is anexpectation that the quantity of nets andamount of insecticide will expand over time,it may be decided to make an initial bulkorder and re-order in response to demand.
If procurement and distribution of nets andinsecticide are to be left to the private sector,the role of the government is to ensure thatthe commercial market is able to obtainsupplies to meet demand.
Bulk buying • Possible economies of scale• Reduced chance of demandexceeding supply (stock-outs)
• Excess of stocks and expiry ofinsecticide if demand creation isinadequate
Standing order
Flexible standingorder
• Ensures a regular supply • May not be adequate to cope withseasonal fluctuations in demand
• Ensures a regular supply that canbe decreased or increased accordingto demand
• Problematic if poor communication • Supplier may not be able to respondto larger variations
Order as required • No stockpiling or insecticide expiry • Risk of stock-outs, which candecrease the motivation ofconsumers and agents
Ordering system Advantages Disadvantages
Table 4.2 Advantages and disadvantages of different approaches to ordering
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Sourcing /Procurement: summary of issues
• Are nets available in local markets, and do they complywith recommended specifications?
• If so, are they sewn locally, manufactured locally,imported?
• Are there, or have there been, donor subsidized netprojects in the area?
• What are the prices of locally available nets and how dothese compare with the cost of importing nets?
• Can any of these supply channels be used for theprogramme?
• What are the constraints?• From where can nets be imported?• Are there any taxes or tariffs on importation of nets or
netting materials?• Are there other partners procuring nets?• What ordering system is most appropriate for the
programme?
• Check with manufacturers and the relevant governmentdepartments which insecticides are fully registeredwithin the country for treatment of nets.
• Are these approved by WHOPES?• Which of these are available in-country and which need
to be imported?• What formulations are available and how do they conform
with the national guidelines?• How reliable are the sources of insecticide and what
technical support is offered by the manufacturer?• Compare prices between manufacturers and for different
formulations.• What are the taxes and tariffs on insecticide? • Are there other partners procuring insecticides?• What ordering system is most appropriate for the
programme?
• What is the size of the target population? And is it ‘closed’?• What are the sleeping habits of this target population?• What are the levels of net usage in this population at
present?• What type of nets are they using?• What do they like or dislike about these nets?• Where did they get these nets from?• What price did they pay for them?• What type of nets would they prefer to use?• What is the affordability of nets within the target population?
• What proportion of those using nets have had them treatedwith insecticide?
• Why did they decide to treat their nets?• How many people have heard of ITNs?• What are their perceptions of ITNs?• How often do net owners wash their nets?• What alternative mosquito biting prevention methods are
used?• What is the cost of these alternative methods of mosquito
control?• Can ITNs compete with/replace this market?
Nets ITNs Insecticide
Supply
Demand
Financingand distribution
Chapter 5
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Approaches to financing and
distribution, like other components
of ITN interventions, must contribute
to and support the national ITN
strategy. It is important to identify
partners that are best placed to
implement the chosen approaches
to financing and distribution.
This chapter covers the main aspects of financing and distribution that needto be considered:
• financing options,
• pricing policy options,
• distribution and delivery options.
Financing and distribution
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Finan
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5.1 Financing options
The options for approaches to financingare:• no-cost recovery,• partial cost recovery,• full-cost recovery.
The following questions and Table 5.2 should beused to select the most appropriate financingoption: ◆ What are the objectives and longer-term vision
of the national ITN strategy? (See Chapter 1)◆ How much will the intervention cost overall?
(See Chapter 3) ◆ How much funding is available?◆ What is the timeframe for funding?◆ Has the donor identified priorities that will
influence financing approaches, for examplesustainability or targeting vulnerable groups?
◆ Has the donor specified what components theywill support?
5.1.1 No-cost recovery
There will be no-cost recovery if nets andinsecticide are given at no charge to thetarget population. Provision of nets andinsecticide at no charge should only beconsidered as a short-term approach, forexample to protect refugee or displacedpopulations during the acute phase of an emergency.
5.1.2 Partial-cost recovery
Most ITN interventions recover some costs, usually through the sale of nets andinsecticide. Different methods can be usedto recover costs (see Table 5.1), and levelsof cost recovery vary. For example, revenuefrom net sales may be used to subsidizethe cost of insecticide in settings wheredemand for nets is high but re-treatmentrates are low. If costs are only partiallyrecovered, revenue generated will be lessthan expenditure. When the original fundsare depleted and eventually used up, this is called a sunset fund.
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5.1.3 Full-cost recovery
Full-cost recovery means that all the costsof an ITN intervention are recovered, notjust the costs of nets and insecticide.Planning for full-cost recovery requirescosting all components of an ITN intervention,including nets, insecticides, research,promotion, monitoring and evaluation, and the costs of staffing, training, logisticsand other activities associated with thesecomponents (see Chapter 3), and sellingnets and insecticide at prices that cover all these costs.
Planning for full-cost recovery must alsotake into account potential losses frominflation and fluctuating exchange rates. If costs are fully recovered, revenuegenerated will cover expenditure. When the original seed funds are replenishedthrough revenue from sales, the fund has “revolved”. If the project continues to cover its costs in full, it becomes a “revolving fund”.
No costs recovered No-charge nets and insecticide to all groups at risk
Some costs are recovered
All costs are recovered
• No-charge nets and insecticide to vulnerable groupsonly, charges for other at-risk groups.
• Charges for nets, but insecticide is at no charge.
• Cross-subsidy of insecticides from net sales.
• Cross-subsidy of one type of net with other types of net(market segmentation).
• Charges for nets and insecticides, but below level offull-cost recovery.
• Sale of nets and insecticide designed to cover allprogramme costs, but losses incurred due to inflation,fluctuating exchange rates, etc.
• Revenue from sale of nets and insecticides covers allprogramme costs.
Level of cost recovery Financing options Common terms
Table 5.1 Financing options
Sunset fund
Sunset fund
Sunset fund
Sunset fund
Sunset fund
Sunset fund
Revolving fund
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Finan
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No-cost recovery Emergency relief
Demand creation only
Targeted distribution tovulnerable groups
• Short-term strategy. • The size of the population at risk should be consideredrelative to the funding available. • Availability of funds for re-treatment of nets should alsobe considered.
• No product sales involved. • Should aim to continue into the medium term. • Need to balance the level of resources and thetimeframe.• Should not be done in isolation from product availability(through alternative sources).
• Should aim to be long term. • The size of the target population and the availability offunding to continue covering this population should beassessed.
Partial cost recovery “Pump-priming”
Social marketing
Sunset funds
Full-cost recovery Revolving funds
• Short-term strategy.
• Timeframe is dependent on donor input.
• Short-term strategy.
For these three strategies, the number of nets andquantity of insecticide that can be delivered with fundsavailable plus revenue generated from the sale of netsand insecticide should be balanced with the proposedtimeframe.
• Long-term sustainability.• The price that nets and insecticides need to be sold atin order to recover fully all costs, including the cost ofnets and insecticide and other components.
Cost recovery Strategy Considerations
Table 5.2 Selecting the most appropriate financing option
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5.2 Pricing policy
For approaches that involve distribution ofcommodities, it is necessary to decide on apricing policy. The most appropriate policy(see Table 5.3) will depend on the financingoption and the strategy selected. Although,in theory, most of these pricing policies canbe applied to both nets and insecticides,nets and insecticides are very differentcommodities. For example, it is easy forconsumers to assess the quality of nets,but it is not so easy for them to assess thequality of insecticide. In addition, demandfor insecticide tends to be lower thandemand for nets. Different pricing policiesmay therefore be required for nets andinsecticide, particularly in places wherere-treatment rates are low.
A policy of no-charge or very low prices
for nets is appropriate both for sustainedsubsidies to promote equity, and foremergency situations. While the pricingpolicy is the same, however, the strategiesare different. Targeting vulnerable groupsis a long-term strategy that requires tightlycontrolled targeting. Emergency relief is ashort-term strategy that requires a differentapproach to targeting. While a policy of no-charge or very low prices for nets is onlysuitable for specific situations, a policy ofno-charge or very low prices for insecticide
Sustained subsidiesfor equity
No-charge or lowprices.
• Availability and sustainability of resources.• The size of the target population.
Revolving fund Prices must cover allcosts (promotion,distribution, handling,administration, etc.).
Social marketing Similar or lower thanthe commercialmarket.
“Pump-priming” Low prices (to encourage uptake)but not too low (toavoid perceptions of low value).
Emergency relief No-charge or lowprices.
• Total costs.• Cost per net and per treatment required tocover all costs or cost per net to cover all costsand allow re-treatment at no charge.
• Cost of nets in the commercial market.• Cost of nets in the commercial market of similarquality to socially marketed nets.• Affordability and willingness to pay of the targetgroup.• Availability and sustainability of resources.
• Affordability and willingness to pay of the targetgroup.• Availability of resources.• Balance between coverage and level ofsubsidy.
• Availability and sustainability of resources.• The size of the target population.• Is it a natural disaster with an endpoint, or acomplex emergency that may become chronic?
Strategy Pricing policy Considerations
Table 5.3 Selecting the most appropriate pricing policy
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may be more widely appropriate, especiallywhere re-treatment rates are low. Beforeimplementing a policy of providingcommodities at no-charge or at very lowprices, it is important to assess the level of funding available relative to the currentand future size of the target population,and the sustainability of funding.
Low prices can be used to encourageuptake of nets and to “pump-prime” thecommercial market. However, this pricingpolicy should only be used for a short time,because ongoing provision of nets at lowprices will undermine the commercialmarket. The level of subsidy, and hence the price set, should be determined by thefunds available, ability and willingness topay of the target population, and coveragetargets.
Social marketing programmes (seeChapter 7) tend to set prices at levels
comparable to, or slightly lower than,
the commercial market. Pricing of nets and insecticides is determined by commercialprices, funds available, ability andwillingness to pay of the target population,and coverage targets. Pricing policies insome social marketing programmes arealso influenced by factors such as cross-subsidies between nets and insecticide,and cross-subsidies between different
Illustration: J Mehra
Figure 14 Nets can be provided at no chargeof at low prices to target vulnerable groups, such as children under five and pregnant women
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types of nets for different segments of themarket. As with low prices, it is importantto ensure that socially marketed commoditiesare not priced significantly lower thancommercial prices, to avoid underminingthe commercial market. Careful marketsegmentation can help.
In situations where the public sectorprovides no-charge or very low pricedinsecticides, for example, the commercialmarket can focus on selling DIY kits forhome treatment of nets.
With a policy where prices must cover
all costs, the prices set will be determinedby the total cost of the intervention and,usually, how many nets will be sold. Insome settings, it may be appropriate toinclude insecticides in the calculation, butin others it may not. Where re-treatmentrates are low, for example, sales ofinsecticide may be too low to cover costs. If the prices required to cover all costs arehigher than market prices, it may not beappropriate to supply nets or insecticide. If nets and insecticide can be sold at priceslower than or comparable to market prices,the intervention can compete on an equalbasis with private retailers.
If the focus is on demand creation only,then there is no need to consider pricing
policy for nets and insecticide, as marketforces will determine prices. This approachassumes that the commercial sector canprovide an assured supply of nets andinsecticide. In practice, this is more likelyto be the case with nets than withinsecticide, and it may be necessary tocombine demand creation with distributionof insecticides.
Pricing policy options for insecticide distribution aspart of a strategy of demand creation
• no-charge initial treatment
• no-charge initial treatment and re-treatment
• low prices to ‘pump-prime’ the commercial market
• cost recovery price of insecticide.
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Finan
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5.3 Distribution and deliveryoptions
The main factors to consider are:• distribution channels,• delivery of nets,• delivery of insecticides.
The following questions should be used to help tomake decisions about distribution and deliveryoptions:◆ Who is responsible for distribution and delivery?◆ What mechanisms are already in place?◆ Where will nets and insecticides be distributed? ◆ What is the target population?◆ What methods will be used for targeting this
group?
Distribution is about how nets andinsecticides are transported to their pointof delivery. Delivery is about how nets and insecticides reach the population ortarget groups. Distribution channels (seeTable 5.4) can be used for both nets andinsecticides. However, delivery outlets and methods for nets (see Table 5.5) andinsecticides (see Table 5.6) may differsubstantially.
Public sector Existing systems, e.g.drug delivery systems
• Reduced costs • Dependent upon theexisting distributionschedule• Nets are bulky andtransport may not beadequate
Establishing newsystems
• Can developdistribution systems inareas where nonepresently exist
• Expensive
On an ad hoc basis • Supply as needed • May be unreliable• Dependent upon goodstock control• Expensive
NGOs and otherorganizations
As part of an ITNprogramme
• Expensive• May not besustainable, especiallyif dependent upondonor funding
Distribution alone • Can use existingdistribution channels,therefore reducingcosts
• May not besustainable, especiallyif dependent upondonor funding
Assisted private sector Combines public orNGO, and privatesector efforts
• Partners carry out theactivities relevant totheir skills andresource capacity• Subsidizingdistribution reducesprices for theconsumer and mayincrease coverage inthe short term.• May ‘crowd in’ thecommercial sector
• Dependent uponeffective collaboration• May not besustainable, especiallyif dependent upondonor funding • May ‘crowd out’ thecommercial sector
Unassisted privatesector
Existing private sectorsystems
• Higher chance ofsustainability
• Dependent upon salesand, therefore, upondemand creation• Need to convinceprivate sector demandwill be generated
Distributor Distribution method Advantages Disadvantages
Table 5.4 Distribution of nets and insecticides
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There are many potential outlets for delivery of nets. The choice of outlet willbe determined by the overall strategy,target groups, ease of access, andresources available.
Delivery of insecticides is more complicatedthan delivery of nets, because it involvesinitial treatment and regular re-treatment of nets. Nets can be treated individually or in small batches on a family basis. Mass dipping of nets is to be cautiouslyrecommended. Community preferencesand resources available will determine theapproach to insecticide delivery.
29 To avoid health workers needing to deal with financial accounting, patients can be given vouchers to exchange at retail outlets.
Government,mission or NGOclinics
Clinic attendees(outpatients)
• Emphasizes the role ofnets as a health careproduct• Links demand creationthrough health educationwith supply at the clinic
• Adds to the workload ofalready overstretchedclinics• Health workers may not bethe best people to deal withfinancial accountingrequired, if nets andinsecticide are not providedat no charge29
• Dependent upon level ofaccess to health facilities
Antenatal andMother and ChildHealth clinics
Under fives,pregnant women
• All of the aboveadvantages• Effective for targetingbiologically vulnerablegroups• Can identify those whoneed no-charge or highlysubsidized nets• Can provide ITNs as partof a package of antenatalcare, including iron andintermittent preventivetreatment
• All of the abovedisadvantages• Dependent upon level ofuse of antenatal careservices by the population
Door-to-door salesagents
Geographic targetcommunity
• Convenient for thecustomer
• Only covers a small area• Requires supervision foraccountability
Retail outlets General population,target population ofa promotioncampaign
• Competition betweenretailers should lead toprice reductions• Convenient for thecustomer• No costs to the publicsector• Potential for widercoverage than throughclinic outlets
• Only covers those who canafford to buy from theprivate sector• Potential for price fixing byretailers
Advantages DisadvantagesOutlet Target
Table 5.5 Delivery of nets
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Community campaigns
Fixed service
• Time community net re-treatment campaigns totake place when communities have cash availableand just before the peak malaria transmissionseason• Make sure people know when a re-treatmentcampaign will take place, so that they can washand dry nets before re-treatment • Dippers must be trained in safe and effectivetreatment of nets
• Can achieve high re-treatment rates in a shorttimeframe, therefore increasing cost-effectiveness• Accessible because re-treatment services cometo the community
• Needs to be able to treat nets of a variety of sizesand shapes, as people may bring a range of netsfor re-treatment• Campaigns may need to be frequent if peoplewash their nets often• Can be expensive (at least some costs borne bypublic sector or NGO organizing the campaign) • May not be sustainable, especially if dependenton donor funding
• Treatment services are offered from a fixed point• Dippers must be trained in safe and effectivetreatment of nets
• People decide when to re-treat their nets ratherthan fitting in with the timing of a campaign
• Less accessible as people must take their nets tothe service point• Relies on people taking the initiative to get theirnets re-treated• Dependent upon the opening hours of the service • Can be expensive (at least some costs borne bycustomer) unless treatment provided at same pointas other services
Mobile service (door-to-door agents)
• Usually operate in a geographically defined area,within reach of where they live • Agents need to record when net owners last re-treated their nets, to enable them to time homevisits when re-treatment is due • Dippers must be trained in safe and effectivetreatment of nets
• Convenient for the customer as the agent comesto their home• Can increase re-treatment rates, especially ifagents are paid on a commission basis• May be more financially sustainable than communitycampaigns or mobile re-treatment teams
• Agents who receive commission linked to thenumber of nets re-treated, may not generatesufficient income to live on• Agents paid on a commission basis may focus ondensely populated, easy to access areas, leavingsome populations unserved
Mobile service (mobile re-treatment teams)
• Mobile re-treatment teams can plan to visit areason a regular basis or provide re-treatment serviceson market days• Mobile teams can also supply nets to those whodo not have them or who need replacements • Make sure people know when a re-treatmentteam will visit, so that they can wash and dry netsbefore re-treatment • Dippers must be trained in safe and effectivetreatment of nets
• Can reach more sparsely populated or lessaccessible areas more effectively than door-to-door agents• Can cover a wider area than single agents
• Can be expensive (for same reasons ascommunity re-treatment campaigns)• May not be sustainable, especially if dependenton donor funding
Home treatment kits(Dip-It-Yourself)
• Intended to make net treatment widely available• Must be accompanied by clear, simpleinstructions to ensure safe and effective hometreatment
• Convenient for the customer• Net re-treatment can be timed to fit in with netwashing frequency• Reduces costs to the public sector, andsustainability not dependent on donor funding
• Can be expensive, because of additional costs ofpackaging and instructions• Poorer families may not be able to afford to buy kits • Need to convince private sector demand will begenerated
Delivery method Key points Advantages Disadvantages
Table 5.6 Delivery of insecticides for net treatment
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Promotion
Chapter 6
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Promotion is an essential
component of ITN interventions,
whether they are implemented
by governments, NGOs, social
marketing organizations, or by
the private sector. Promotion plays
a critical role both in creating
demand for nets and treatment
of nets, and in encouraging
appropriate use of ITNs.
This chapter provides an overviewof the important steps in promotion,which are to:• define promotion objectives
• plan implementation
• develop messages
• identify communication channels
• pre-test, post-test and evaluate.
Promotion
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6.1 Define promotion objectives
The purpose of any promotional campaignis to increase coverage and use of ITNs.This usually involves changing people’sbehaviour by:• increasing knowledge of the health
benefits of using ITNs;• promoting positive attitudes towards
malaria control and ITNs;• minimizing barriers to behavioural
change.
Promotional campaigns should providepeople with the information they needabout malaria, about the role of ITNs inmalaria prevention, and about why andhow to treat their nets with insecticide.
Such campaigns also need to promotepositive individual and social attitudes
to malaria control and ITNs including, forexample, appreciation of the severity ofmalaria, perception of personal risk, useof ITNs as a social norm, and the economicbenefits associated with use of ITNs.
Promotional campaigns cannot address all of the barriers to ITN use. For example,promotion can influence willingness to pay and those who make decisions abouthousehold expenditure. But promotion can do little to increase the availability
Figure 15 Barriers to behavioural change
KnowledgeBarriers
Behaviouralchange
Attitude
94
or affordability of nets and insecticides (seeChapters 4 and 5).
Increasing knowledge, promoting positiveattitudes, and minimizing barriers areimportant overall objectives. But the specificobjectives for promoting behaviouralchange in a specific context must be defined.
The following questions should be used to help todetermine promotion objectives:◆ What aspects of people’s knowledge and
understanding of malaria, its causes andprevention, need to be improved?
◆ What attitudes towards malaria and its prevention,including use of ITNs, need to be promoted?
◆ What negative or blocking perceptions need to be addressed?
◆ What aspects of treated net use need to beimproved?
The specific objectives will be determinedby the findings of the assessment of thecurrent knowledge, attitudes, enabling orblocking perceptions, and practices of thetarget population (see Chapter 2), as theexamples in Table 6.1 illustrate. Theseobjectives will also feed into the plans formonitoring and evaluation (see Chapter 3).
No understanding of malaria as a severedisease or how it is transmitted, or of howITNs protect against malaria.
Increase understanding of malaria and of therole of ITNs.
Good general understanding of malaria, butno use of ITNs.
Increase understanding of the role of ITNs inprotecting against malaria; increase use ofITNs.
Nets or ITNs are used but re-treatment ratesare low.
Increase understanding of the importance ofre-treatment; increase rates of re-treatmentof ITNs.
Findings from assessment Promotion objectives
Table 6.1 Using assessment of current knowledge, attitudes and practices (KAP) to develop promotion objectives
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6.2 Plan implementation
The following questions should be used to help toplan implementation:◆ What approach to promotion will be taken?◆ Who will carry out promotion activities?◆ What is the target audience for promotion
activities?◆ When will promotion activities be carried out?
6.2.1 Approach
Possible approaches to promotion include:• Generic promotion, which involves
promoting the type of product, for examplenets in general rather than a specific brand.
• Umbrella branding, which attempts tocapitalize on the power of brand advertisingwithout promoting any one brand overanother.
• Brand advertising, which is the approachused by the commercial sector and byproduct-based social marketingprogrammes, to promote a specific brand.
• Hybrid approach, which may involvea generic campaign to educate thepopulation about malaria and the role ofITNs, combined with umbrella or brandadvertising.
6.2.2 Implementing agencies
The NMCP does not necessarily need to implement promotional campaigns. It is more important for the NMCP toidentify organizations with the capacity and expertise to contribute to promotionalcampaigns, to work in partnership withthese organizations or promote collaboration,and to ensure that promotional activitiesand messages are complementary.Organizations with suitable skills andexperience may include advertisingagencies, marketing boards, socialmarketing organizations, radio andtelevision stations, and commercialmanufacturers of nets and insecticides.
If the NMCP does play a role in promotion,it should focus on generic messages aboutmalaria, and the role and use of ITNs, andleave the advertising of specific brands ofITNs to the private sector, social marketingorganizations and NGOs. It could alsoencourage NGOs and community educatorsto adapt and use participatory behaviouralchange tools, such as the ParticipatoryMalaria Prevention and Treatment packagethat has recently been developed for usewith communities in Mozambique.
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6.2.3 Target audience
The findings of the assessment shouldhave identified who needs to be targetedby a promotional campaign. The targetaudience may include intended users,household decision-makers, carers, andinfluential people in the community.
Pregnant women are usually an importanttarget group for promotion, to ensure thatthey use ITNs to protect themselves andtheir children against malaria. However,women may not always be able to makedecisions about the purchase of commoditiessuch as nets, and household decision-makers may be an important secondarytarget audience for promotion.
The target audience for promotion may notnecessarily be the same as the target groupfor ITN use. For example, if protection ofchildren under five is a priority, promotionwill need to target mothers, fathers andothers who care for young children.
Community or religious leaders, traditionalhealers, grandparents and others whoinfluence people’s behaviour may also needto be targeted by promotional campaigns.
6.2.4 Timing
Promotional campaigns should only becarried out when systems for supply anddistribution of nets and insecticide are inplace. It is a waste of effort, and may evenbe counterproductive, to create demandthat cannot be met.
Sustained promotion is necessary tomaintain and increase sales of nets andinsecticides. However, more intensiveefforts to promote nets should be timedto coincide with the season when thetarget audience has cash available (seeChapter 2). Similarly, efforts to promoteinsecticide should take place just beforethe peak malaria transmission season.
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6.3 Develop messages
Messages should be determined by thefindings of the assessment and the specificpromotion objectives that have beenidentified. It is important to design messagescarefully and to think about their possibleimpact. For example, in many communitiesthe main motivation for net use is protectionfrom nuisance biting and it may be temptingto develop messages that promote ITNs as a way of getting a good night’s sleep.Such messages may increase householdcoverage with ITNs, but they may alsoresult in ITNs only being used at timeswhen nuisance biting is a significantproblem, which means that people will notbe protected from malaria transmissionwhen nuisance biting is low. Such messagesmay also result in ITNs being used by wageearners for whom a good night’s sleep isperceived to be more important, ratherthan by children under five and pregnantwomen, who are most vulnerable to malaria.
Messages should therefore focus on thehealth impact of ITNs.
The following questions should be used to help toplan message development:◆ What are the main messages to be communicated?◆ How many important messages are there?◆ What language and local terms will be used?
Messages should be:• simple,• clear,• understandable,• informative,• memorable,• positive,• specific,• interesting,• culturally appropriate.
Examples of messages include:
• Malaria is transmitted by a particular typeof mosquito.
• Malaria is a serious disease that can kill people.
• Children under five and pregnant women are mostat risk of severe malaria disease.
• Malaria can be prevented.
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• A mosquito net protects against biting by actingas a physical barrier and therefore protectsagainst malaria.
• Treating a net with insecticide increases theprotective effect by repelling and killingmosquitoes.
• Treated nets will also kill bedbugs, fleas and headlice.
• Nets must be re-treated with insecticide afterthree washes.
• Sleep under a treated net every night.
6.4 Identify communicationchannels
Communication channels should beappropriate for the target group and forthe messages to be delivered.
The following questions should be used to help todecide about communication channels:◆ How does the target audience or audiences
normally obtain or receive information?◆ What communication channels are available?◆ Which of these channels is appropriate for
different messages and target audiences?
Potential communication channels includeinterpersonal contact, drama, radio,television and print media, and advertisingbillboards. Each has advantages anddisadvantages. For example, interpersonalcontact and drama are more interactive butreach fewer people, whereas television andadvertising are less interactive but reacha larger audience. These examples arediscussed in more detail below.
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Interpersonal contact usually involvesperson-to-person communication betweenprogramme staff, health staff or communityleaders and community members.Interpersonal contact can use locallyappropriate terminology and provides anopportunity for discussion and clarificationof messages. It can target specific groupsselectively and achieve a good impact incommunities, especially in rural areaswhere there is greater communitycohesiveness and potential for informationsharing by word of mouth. Interpersonalcontact tends to achieve low coverage anda low rate of message repetition, however,and the cost per person reached is relativelyhigh because of intensive staff inputs.Training and transport may also add to thecosts. There may also be difficulties inensuring quality control of messages andthe way in which they are delivered.
Drama and other entertainments areother examples of community-basedcommunication channels. Drama, usingprofessional or non-professional groups,can include theatre, song, dance andpuppet shows. Other entertainmentmethods may include storytelling andpoetry. Entertainment events are usuallyvery popular, especially in rural communities
Figure 16 Drama or role play, the radio, and personalcommunication are all methods that canbe used to promote ITNs
Illustration: J Mehra
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who do not have access to television. It is important that messages deliveredthrough entertainment are simple andclear, because there is a possibility that the audience may be distracted by theentertainment and not take in themessages. Drama may only reach a limited audience and may be expensive if a professional group is employed, but using local groups, health students,community health educators or othervolunteers can increase coverage andreduce the cost.
Television has the potential to reach a largeaudience and to get across messages veryeffectively. In many countries, however,television is only accessible to people livingin urban areas or in wealthier socio-economic groups. When deciding about the use of television in a promotionalcampaign, the following factors should beconsidered: access to television among thetarget audience(s); channels available, thegeographical areas they cover, and thetypes of programmes they transmit; peakviewing times and times when the targetaudience(s) are most likely to watchtelevision; and the cost of television spots.
In many countries, radio reaches a largeraudience than television and it may be themost effective communication channelavailable. The issues the need to beconsidered when deciding about the useof radio are the same as for television.
Print media such as newspapers andmagazines also have the potential forreaching a large audience, depending ontheir frequency, circulation and readership,and on literacy levels. Other types ofprinted materials, such as newsletters and leaflets, can be used to target specificgroups, such as health workers, retailers,and community leaders. Where literacylevels are low, pictures can be used to communicate a certain amount of information.
Outdoor media, such as billboards placedin prominent areas, are a useful formof advertising.
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6.5 Pre-test, post-test and evaluate
No matter how much care is taken indeveloping messages, they should alwaysbe pre-tested with a sample of the targetpopulation before a promotional campaignis launched. Pre-testing, which is usuallyconducted through focus group discussionsor in-depth interviews, can help to avoidexpensive mistakes. Use the feedback from pre-testing to modify messages andmaterials. It may be necessary to pre-testmessages and materials more than once.Important things to assess during pre-testing are summarized below.
Perceptions about nets and insecticide will change as a result of promotion. So post-testing, which involves monitoringthe campaign periodically and makingmodifications as required, is also important.Messages and communication channelsshould be checked and revised on a regularbasis, to make sure that they are stillappropriate and relevant, and to ensurethat promotion is still achieving maximumimpact. Another reason for post-testing isthat, after a time, people get bored withhearing the same messages and tend notto notice them any more.
• Presentation. Does the audience like the wordsand pictures?
• Attention. Does the message hold the audience’sattention?
• Comprehension. Does the audience understandthe message as intended?
• Personal relevance. Does the audience see themessage as personally relevant? Do they identifywith the people and situations shown?
• Believability. Does the audience perceive themessage and its source to be credible?
• Acceptability. Does the audience find the messageacceptable?
Source: Chavasse D, Reed C, Attawell K. Insecticide-treated net projects: ahandbook for managers. Malaria Consortium, 1999.
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In addition to ongoing monitoring ofmessages and communication channels,it is important to evaluate the impact of thepromotional campaign (see Chapter 3).
Source: Mehra S. Partnerships for change and communication: guidelines for malaria control.WHO/Malaria Consortium, 1997.Illustration: J Mehra.
Figure 17 It is important to pre-test promotion materials with a smallergroup before using them with the wider community
Social marketing
Chapter 7
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Social marketing is an approach
that has been used to increase ITN
coverage and is used in many
countries. Before deciding what
role social marketing will play
in the national strategy, it is
important to understand what
social marketing involves and how
it fits with ITN interventions by the
public and private sectors.
This chapter provides an overviewof social marketing and itscomponents, including:• planning
• product
• price
• place
• promotion.
Social marketing
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7.1 What is social marketing?
Social marketing is different from commercialmarketing. Commercial marketing is aboutinfluencing behaviour to achieve commercialobjectives, whereas social marketing isabout influencing behaviour to achievesocial objectives. Social marketing usescommercial marketing techniques andtools – such as market segmentation,consumer research, product branding, and promotion – but, unlike commercialmarketing, social marketing targetsvulnerable populations, aims to keep pricesas low as possible, and emphasizes thehealth benefits of ideas, products or services.
Social marketing aims to create awarenessof, and demand for, new ideas, products or services and to motivate acceptance of these ideas, products or services bypromoting their benefits, in addition tomaking them economically accessible. It is particularly effective when there isa clear target audience and a specificbehaviour to influence, and can be appliedto a range of public health issues.
Social marketing recognizes that theprocess of behavioural change involvesfour different stages: pre-contemplation,contemplation, action, and maintainingaction. Using the example of ITN use to
Defining social marketing
Social marketing employs a range of differentapproaches. It applies marketing tools and concepts toencourage positive behavioural changes among thosewho are under-served by existing public and privatesystems. It advertises and promotes commodities,services and behavioural change through mass,traditional and interpersonal media, and chargessubsidized prices for products and services at retailoutlets and clinics, and through community groups.Behavioural change strategy promotes access to anddemand for goods and services by integrating healtheducation with commercial brand advertising.
Social marketing incorporates the four ‘P’s:
• Create an enticing ‘Product’ or package of benefitsassociated with the desired action.
• Minimize the ‘Price’ that the audience believesit must pay in exchange.
• Make the exchange and its opportunities available in‘Places’ that reach the audience and fit its lifestyles.
• ‘Promote’ the exchange opportunity with creativityand through channels and strategies that maximizedesired responses.
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prevent malaria, an individual needs torecognize that they are at risk of malaria,to decide to use ITNs, and to use themconsistently. Product-based socialmarketing develops and communicatesmessages to raise awareness of the healthrisks that may be reduced or solved bypurchase and use of the social marketingorganization’s product. Social marketingalso recognizes that behaviour andbehavioural change are driven by the trade-off between benefits and costs, by whatothers are doing, and by personal experience.
Understanding the target audience, the barriers to behavioural change and the factors that encourage behaviouralchange, is crucial. This “customer-centred”approach, characteristic of the privatesector, differentiates social marketing fromthe organization-centred approach that isoften characteristic of the public sector.Listening to the “customer” is critical, andinvestment in formative, pre-testing andmonitoring research—and adjustment ofapproaches based on the findings of thisresearch—is a crucial aspect of socialmarketing.
Figure 18 Understanding the target audience is a vitalpart of social marketing
Source: Mehra S. Partnerships for change and communication: guidelines formalaria control. WHO/Malaria Consortium, 1997. Illustration: J Mehra.
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7.2 Planning
Like any other ITN intervention, socialmarketing must be planned on the basisof information collected during assessment(see Chapter 2). To enable social marketingprogrammes to plan effective marketsegmentation, product branding, deliveryand promotion, it is especially importantto find out about:• socioeconomic status of target groups;• preferences for different types of nets
and insecticides;• acceptability of different brands
of products;• access to different distribution and
delivery outlets;• knowledge and attitudes of target groups;• media access and habits of target groups.
Most ITN social marketing programmesare involved in promotion, distribution anddelivery of nets and insecticides. But eachprogramme needs to decide what mixof the four ‘Ps’ is most likely to achieve the desired objectives.
The following questions, and the following sections,should be used to help to decide on the best mix:
PRODUCT (see Chapter 4)◆ What products and brands will be targeted at
which segments of the market?
PRICE (see Chapter 5)◆ Will the cost of products be subsidized?◆ What approach to subsidy will be taken, e.g.
blanket subsidies, cross-subsidies, targetedsubsidies?
◆ Will the programme aim to recover costs? Will this be partial or full-cost recovery?
◆ Will consumers be expected to pay for products at the time of purchase or will credit schemesbe introduced?
PLACE (see Chapter 5)◆ What outlets are appropriate for the target
groups?◆ How will leakage of subsidized products to other
segments of the market be prevented?
PROMOTION (see Chapter 6)◆ What messages will be delivered by the
promotional campaign?◆ What is the target audience for the promotional
campaign?◆ What communication channels will be used to
deliver messages to the target audience?
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7.3 Product
The main issues to consider are:• nets,• insecticide treatment,• branding,• market segmentation.
7.3.1 Nets
• The information from the assessmentshould be used to determine the mostappropriate type of nets, in terms offabric, shape, size and colour, for thetarget population.
• Use the same information to decidewhether or not it is necessary to promotedifferent types of nets to differentpopulations, for example, rectangular netsto rural populations and conical nets tourban populations.
• Find out where nets that meet the desiredspecifications can be sourced atreasonable cost.
• Choose a procurement and orderingsystem that is appropriate for theprogramme, or a partner organization with experience inprocurement.
• Decide how the nets will be packaged,and whether or not they will be packagedwith a single treatment dose ofinsecticide.
7.3.2 Insecticide treatment
• The information from the assessmentshould be used to determine the mostconvenient way for delivery of nettreatment and re-treatment to the targetgroup, for example, home treatment,treatment at a fixed facility, treatmentby door-to-door agents.
• Use the same information to decidewhether or not there is a need for a rangeof options for delivery of net treatment and re-treatment.
• Find out where insecticides in theappropriate packaging for the selecteddelivery mechanism can be sourcedat reasonable cost.
• Choose a procurement and orderingsystem that is appropriate for theprogramme, or a partner organization with experience in procurement.
• Decide how the insecticide will bepackaged and whether or not insecticidewill be included with nets or distributedseparately.
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7.3.3 Branding
Using the commercial marketing techniqueof branding, with the development of logosand attractive packaging, increases theuptake and use of socially marketed products.This is because branding has the potential:• to increase the perceived quality of
the product;• to create a product image that is
attractive to the target group;• to encourage behavioural change;• to increase sales of other generic
products through the ‘halo effect’, wherepromotion of one particular brand alsoincreases sales of other non-branded ordifferently branded products throughexpanding the market as a whole.
A social marketing programme will need todecide about net and insecticide branding,including whether or not different brandnames and logos will be used if more than one type of net or insecticide is to bepromoted to different segments of the market.
7.3.4 Market segmentation
Commercial marketing segments themarket into different types of consumerswith different preferences, and targetsdifferent brands of products to differentsegments of the market. This technique isused to increase the total volume of salesof a particular type of product. For example,some brands of soap are sold as beautyproducts and others are sold as babyproducts and, as a result, the total volumeof soap sales is higher than if just onebrand of soap were available.
Net markets can be segmented in the sameway, for example with white, conical netstargeted at the urban market and blue,rectangular nets targeted at the ruralmarket. In principle, market segmentationcan also be used to prevent subsidized netsprovided by social marketing organizationsand the public sector from undermining or‘crowding out’ the commercial net market(see Chapter 1 and section 7.4.3).
This involves identifying the consumers to be targeted by subsidized products and the consumers to be targeted by thecommercial market, and developing,promoting and selling different brands to these different groups of consumers. One potential disadvantage of this
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approach, however, is the developmentof an illegal market, with people “sellingon” subsidized nets to generate income.
There are two ways to define the targetgroups for subsidized products:• those who are most vulnerable to
malaria, i.e. children under five andpregnant women;
• those who are least able to afford to buynets and insecticides, i.e. the poorestsocioeconomic groups and households.
In practical terms it is easier to targetsubsidized products at children under fiveand pregnant women, as these groups areclearly identifiable and can be reachedthrough antenatal and Mother and ChildHealth (MCH) clinics. Targeting the poorestis less straightforward, because it is notalways easy to achieve communityconsensus about which groups andhouseholds are the most economicallydeprived.
7.4 Price
The main issues to consider are:• pricing structure,• cost recovery,• subsidies.
7.4.1 Pricing structure
Social marketing programmes usually sellnets and insecticide for around the same orslightly lower prices than the commercialmarket. The pricing structure for socialmarketing programmes will be determinedby private sector prices, in addition toassessment of ability to pay (see Chapter 2)and the approach to financing adopted (seeChapter 5).
7.4.2 Cost recovery
Most social marketing programmes aim forsome cost recovery, usually the total costof nets and/or insecticide or a proportion of the costs of these commodities. Socialmarketing programmes rarely try to recoverother programme costs, such as formativeresearch, promotion or distribution, andthese are often covered by donor funds.This is because the level of cost recoverymust be weighed against the level ofcoverage. Higher product prices will increase
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cost recovery, but may result in lower salesand coverage. Conversely, lower prices willdecrease cost recovery, but may result inhigher sales and coverage.
The extent to which social marketingprogrammes aim to recover costs willtherefore depend on the size of the targetpopulation, its socioeconomic status, andthe donor resources available to supportnon-product costs. Chapter 5 providesadditional information about cost recovery.
7.4.3 Subsidies
Subsidies are intended to make nets andinsecticides more affordable to the targetpopulation and, thereby, to increasecoverage. There are several potentialapproaches to net and insecticidesubsidies:
Blanket subsidies, where the cost of all netsand insecticides are reduced by a certainamount, for example a US$ 4 net is sold for US$ 3. Reducing the cost from US$ 4 toUS$ 3 is likely to increase affordability onlyfor a small proportion of the population. In addition, this approach subsidizes thebetter off who can afford to pay US$ 4, but still excludes the poorest who cannotafford to pay US$ 3.
Cross-subsidies, together with marketsegmentation and branding, where sometypes of nets are sold at higher prices tothe better off and other types at lowerprices to the poorest. Specially brandednets targeting the more affluent urbanmarket may be sold at above cost priceand the profit used to subsidize the price of a differently branded net for ruralpopulations (see Chapter 5). An alternativeapproach is selling nets at above cost priceand using the profit to provide no-chargeor subsidized insecticide treatment. This approach has been used in settingswhere demand for nets is high butre-treatment rates are low.
Targeted subsidies, where the subsidizedcommodities are targeted to the mostvulnerable or the poorest groups. Fewsocial marketing programmes haveimplemented tightly controlled targetingof this kind.
As discussed in section 7.4.2 on costrecovery, other social marketing programmecosts, such as formative research, promotionand distribution, are often subsidized bydonors. In addition, donor-supported socialmarketing programmes are “subsidized” in that they, unlike the private sector, areexempt from import tariffs on nets andinsecticides.
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Without careful market segmentation andtargeting, subsidized nets and insecticidesmay undermine the existing private sectoror prevent the development of a commercialmarket. It is therefore important to monitorthe potential impact of subsidized productson the commercial sector (see Chapter 3).
7.5 Place
The main issue to consider is distributionchannels and outlets.
7.5.1 Distribution channels and outlets
Social marketing programmes deliver netsand insecticides to consumers through avariety of distribution channels and outletsin both the public and private sectors.Potential distribution channels and outletsinclude public sector health facilities andprivate sector marketing. The distributionchannels and outlets must be selected onthe basis of their appropriateness to thetarget group and to the type and brand of product. Chapter 5 provides more detailsabout different distribution channels and outlets and their advantages anddisadvantages. It is also essential to makesure that nets and insecticides are availablethrough the selected channels and outletsbefore launching promotion activitiesto create demand (see Chapter 6).
Public sector delivery of nets in socialmarketing programmes usually focuses onreaching children under five and pregnantwomen through antenatal and MCH clinics.Delivery through the public sector isappropriate for targeting vulnerable
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groups, and promotes nets and insecticidesas far as possible as health products.
Private sector distribution of nets suppliedby social marketing programmes is anotherapproach. This is a form of assisted privatesector distribution, based on a partnershipbetween a social marketing organizationand the private sector, where the socialmarketing organization supports distributionsystems in the short term until demand iscreated and a viable commercial market isestablished. This type of partnership alsoallows the commercial market to benefitfrom import tariff exemption, while effortsare made to eliminate all taxes and tariffson nets and netting.
Public and private sector marketing of
insecticide could be carried out throughoutlets including public health facilities,pharmacies and shops. The outlets selectedwill depend on the way in which insecticideis branded and packaged. Distribution of insecticides for treating nets must beregulated to prevent misuse, so outlets inthe informal sector may be less appropriatefor insecticides than for nets.
Figure 19 Sales agents that travel to communitiescan make nets more accessible
Source: Chavasse D, Reed C, Attawell K. Insecticide-treated netprojects: a handbook for managers. Malaria Consortium, 1999.
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7.6 Promotion
Promotion plays a critical role in all ITNinterventions, including social marketingprogrammes, both in creating demandfor nets and treatment of nets, and inencouraging appropriate use of ITNs.Chapter 6 provides more detailedinformation about promotion.
Aspects of promotion that are of particularimportance in social marketing programmesinclude brand advertising through the massmedia, interpersonal approaches and salespromotion.
Like the commercial sector, socialmarketing programmes take a brand
advertising approach to promotion.Specific brands are usually advertisedthrough television and radio campaigns.Radio tends to have wider coverage andis less expensive than television, buttelevision is a powerful medium for creatingbrand image, product awareness, andperceptions of quality among consumers,traders and opinion leaders.
In social marketing programmes,interpersonal approaches at communitylevel, through road shows, special eventsand direct sales by sales representatives,are important channels for promotion,especially to rural populations. Health
workers, shopkeepers and pharmacists canalso be important promoters of products totheir clients.
Sales promotions can be used to launchpromotion campaigns. For example,consumers could be offered time-limitedspecial offers, such as 3 for 2, buy 1 get1 free, buy a net and get the insecticide kitat no charge. Sales representatives andothers involved in promotion need supportingpromotional materials. Special promotionalevents, billboards and printed material canalso help to support promotion activities.
Roll Back Malaria is a global partnership founded by thegovernments of malaria-afflicted countries, the World HealthOrganization, the United Nations Development Programme,the United Nations Children's Fund and the World Bank. Its objective is to halve the burden of malaria for the world'speople by the year 2010 by saving lives, reducing poverty,boosting school attendance and making life better for millionsof people living in poor countries, especially in Africa.
If you are interested in becoming part of the Roll Back Malariamovement, receiving the RBM newsletter and becoming partof the global success story in reducing malaria, please write to:
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Switzerland
Fax: +41 22 791 48 24E-mail: [email protected]
Internet: http://www.rbm.who.int/
Roll Back MalariaWorld Health Organization20 Avenue AppiaCH-1211 Geneva 27Fax: +41 22 791 48 24E-mail: [email protected]: http://www.rbm.who.int/
Insecticide-treated mosquito net interventions
A manual for national control programme managers
This book provides a practical guide to all factors – from price and technical qualities to accessibility and communityacceptance – that need to be considered when planning to increase population coverage with insecticide-treated nets.Addressed to the managers of malaria control programmes, the book draws on over 15 years of experience in endemiccountries to identify strategic options for increasing coverage and then explain their advantages and disadvantagesin terms of specific programme objectives. Details range from advice on how to secure sustainable funding, throughinstructions for calculating the number of nets needed for a given target population, to the simple observation that whitenets are subject to more frequent washing. Throughout, emphasis is firmly placed on development of the commercialmarket as the only realistic and sustainable option for securing wide-scale population coverage with treated nets.Managers are also advised to organize the sourcing and procurement of nets and insecticides as separate operations,as the commercial market for insecticides is virtually nonexistent. The book has been issued by WHO in response to both the documented effectiveness of nets as a strategy forreducing malaria transmission and the low population coverage achieved to date. It aims to give endemic countries allthe expert advice needed to accelerate the introduction and use of insecticide-treated nets. With this goal in mind,numerous tables, charts, checklists, drawings, and alerts to common pitfalls are used to enforce the book’s abundantpractical advice.The book has seven chapters. The first describes the role of insecticide-treated nets in reducing the risk of malariatransmission and discusses ways to create an enabling environment for the commercial sector. Chapter two explainshow to develop an appropriate national strategy based on an assessment of factors ranging from domestic conditionsand mosquito biting habits to malaria epidemiology and community attitudes. Subsequent chapters provide a step-by-step guide to the planning, monitoring and evaluation of a national intervention strategy, and discuss the sourcing andprocurement of nets and insecticides, giving particular attention to the many factors beyond price that influence cost-effective investments. A chapter on financing and distribution covers options for securing funds and establishing pricingpolicies that influence demand, growth of the commercial market, and coverage of vulnerable groups. The remainingchapters provide a how-to guide to the use of promotion and social mobilization to support national strategies for rapidlyincreasing population coverage with insecticide-treated nets.
WORLD BANK
World HealthOrganization
ISBN 92 4 159045 9