Malaria Matters: Issue 11, February 2003

This issue of Malaria Matters - Featuring Netting News was funded by Syngenta. They can be reached at: WRO-1004.6.52, Schwarzwaldallee 215, CH-4002 Basel, Switzerland, phone: +41 61 323 5490, fax: +41 61 323 5608, john_pattrick.koenig@syngenta.com, www.syngenta.com.

The UNICEF Role in Scaling-up ITN Coverage in Africa

By Mark Young, MD, MHSc

Background

Although ITNs are a very powerful malaria prevention tool, experience to date in Africa indicates that ITNs are currently too expensive or unavailable to those segments of the populations that experience the greatest malaria burden: pregnant women, children under five years of age, and those individuals and communities in the poorest quintile. UNICEF's recent Multiple Indicator Cluster Surveys (MICS) revealed very low overall coverage of ITNs in Africa (less than 10%), and, of greatest concern, less than 1% coverage for young children.

The RBM Partnership, through the Technical Support Network for Insecticide-Treated Materials, has developed a framework for ITN scale up (Scaling-up insecticide-treated netting programmes in Africa: A Strategic Framework for Coordinated National Action. August 2002; RBM, Geneva). The Framework recognizes that countries are at different stages of implementing ITN policies, and will therefore need local adaptation of regional policy. National policy on ITN implementation will be determined by national Governments in consultation with RBM partners at regional and country levels. Hence, it is anticipated that there will be considerable diversity in the core elements of national approaches, including financing and distribution schemes for ITNs.

UNICEF´s Role

To ensure equity, it is UNICEF´s position that the price of ITNs should not constitute a barrier to ownership of ITNs especially by the most vulnerable population groups, pregnant women and young children. UNICEF supports the RBM ITN Framework as a guide for national policy and program development. Based on mission and institutional capacities, UNICEF will emphasize the following precepts in supporting maximal acceleration of ITN coverage in Africa:

• The focus must be to ensure universal ITN coverage for infants and young children, pregnant women, and lactating women and their infants.
• For these populations with the greatest burden of malaria, ITN cost to the consumer should never be a limiting factor in attaining and sustaining the highest possible coverage.
• National health systems should initially strive to achieve high ITN coverage, targeting the most vulnerable groups in accordance with the Abuja targets, while stimulating the private sector as a medium to long-range objective.

UNICEF Supply Division is procuring increasingly greater supplies of ITNs each year, with almost 4 million procured in 2002. This has resulted in a gradual reduction in prices, to about USD $1.50 for a family size net (from about USD $3.50 in 1999), and about USD $0.50 for insecticide treatment kits, with a continuing expansion of the number of potential suppliers from African countries.

Currently a critical limiting factor in scaling up ITN coverage is the absolute limits on the quantity of ITNs being produced globally. UNICEF in consultation with RBM partners will develop estimates of annual ITN requirements, and in partnership with the Global Fund to Fight AIDS, TB and Malaria (GFATM) and other national program funding agencies, projections of the global financial support for ITNs. With these data, UNICEF will develop approaches to industry to stimulate expansion of ITN production to meet global malaria control requirements.

UNICEF recognizes the programmatic advantages of long-lasting insecticide treated net (LLITN) technology, but also recognizes current technology and production limitations. UNICEF will continue to work with partners to ensure that this technology is developed and that LLITN production capacity is increased.

During the next three years UNICEF Africa regional and country offices will focus on scaling up use of ITNs, to include the following:

• Procure and supply affordable ITNs and re-treatment kits targeting the most vulnerable groups, especially children under five and pregnant women.
• Distribute ITNs to populations in emergencies and those affected by natural disasters.
• Work with Ministries of Health to create demand, using radio, media, drama groups, IEC materials and other participatory approaches for social change communication.
• Work with NGOs and social marketing groups to target hard to reach populations and poor families especially in rural areas.
• Develop community capacities to conduct net retreatments every six months using Community Health Workers as necessary for education, distribution of insecticide treatment kits, and mass treatment campaigns.
• Advocate for reduction of taxes and tariffs on ITNs to make them more affordable to the poor.
• Support community health schemes to distribute ITNs and re-treatment kits, for example in the Bamako Initiative programs in West Africa.
• Community Capacity Development activities centered on malaria prevention and effective treatment.

Programming Action Steps

UNICEF will focus efforts for ITN scale-up in Africa within its malaria programming approach, which aims to strengthen programme partnerships for maternal and child health (MCH). This approach targets UNICEF programme efforts in prevention partnerships for the highest risk populations (infants and pregnant women) and in integrated case management programmes at entry health facility level and in the community.

Strengthening Antenatal Care

As a component of effective antenatal care, the provision of ITNs will be combined with Intermittent Preventive Treatment (IPT) in partnership with national reproductive health and Safe Motherhood programmes. UNICEF will work with RBM Partners to adopt a birth cohort approach to the distribution of ITNs. Such an approach, if compatible with national policy, would ensure the provision of an affordable ITN to each pregnant woman at the first antenatal visit. National programmes are currently experimenting with various pricing and distribution schemes to accomplish this program goal, and UNICEF will work as a RBM partner to evaluate the coverage and impact of programming efforts.

Strengthening Infant Health

ITN distribution can be linked with routine immunization through routine EPI programming. Infant and child health prevention programming emphasizes universal ITN coverage of all infants, initially under the mother's ITN where nursing infants sleep with the mother. UNICEF proposes to adopt an infant cohort approach to ensuring that the prime caregiver for every infant receives an ITN in conjunction with either DPT3 or measles immunization to ensure ITN coverage for every child through infancy. In selected instances, ITN distribution to children under five linked to planned immunization campaigns such as measles may be appropriate. Provision of insecticide re-treatment kits could also be considered in this way.

Case Management of Childhood Illness

The encounter of the sick child and caregiver with a health worker represents a unique opportunity to provide appropriate messages relating to the use of ITNs. Under some circumstances, national programmes may adopt components that, in addition, provide an ITN or a voucher or other credit for the procurement of an ITN.

Forecasting and Supply

UNICEF is developing estimates for the annual ITN requirement for Africa based on the cohort programming approach as outlined. Further, UNICEF has committed to leadership in stimulating global ITN production capacity. Partnership with GFATM and other funding agencies to carefully estimate annual ITN funding capacity for Africa will be an essential factor in ensuring that global and regional production capacity respond to Africa´s ITN requirements.

The Way Forward

The burden of malaria in Africa can be controlled with the tools that are currently available, and increasing the access of populations in poor countries to ITNs is both desirable and feasible. UNICEF is committed to the challenge of increasing coverage of integrated packages of malaria prevention and control interventions, delivered through strengthened maternal and child health services and the community, backed by good technical support and supervision. The following case study of UNICEF efforts to improve ITN coverage in Mozambique is but one example.

Dr. Mark Young, Senior Health Advisor, UNICEF, Three United Nations Plaza, New York, NY 10017 USA, myoung@unicef.org

Case Study: Community Capacity Development and Malaria in Mozambique

Background

In Mozambique malaria accounts for 40% of out-patient consultations, 60% of paediatric in-patients and a third of hospital deaths. Malaria is a significant contributing factor in the high infant and under 5 mortality rates observed in Mozambique. It is also a serious illness in pregnant women, resulting in severe anaemia. As well as making the mother ill, malaria infection during pregnancy leads to low birth weight of the child, perhaps the most important factor in determining a child´s future survival and development. Poor, rural communities tend to suffer the effects of malaria more than urban ones due to increased transmission intensity, poorer access to preventive and curative services, and reduced knowledge of the risks of malaria and the potential measures for its prevention and control.

Strategy pursued to address the problem

A community capacity development (CCD) strategy, guided by the principles of human rights based programming, is under implementation by UNICEF in Zambzia and Gaza Provinces. Key components of this strategy are the use of participatory approaches to empower communities to analyse their situation and select appropriate tools to overcome the identified problems. A participatory toolkit has been developed to improve knowledge regarding malaria, sanitation, hygiene and nutrition. Allied with the CCD component are interventions to improve access to malaria prevention and treatment. Community councils are the key forum through which a community situation analysis is carried out, problems are identified and action taken by communities. Where malaria is identified as a priority, support is provided to ensure access to ITNs and first-line drugs for treatment of malaria as close to home as possible. ITNs are available through social marketing at retail outlets, and through targeted, subsidised delivery to children under five and pregnant women via health facilities and community councils.

Results so far

Implementation commenced in two districts in Zambzia, has expanded to 12 districts, and will be implemented throughout the province (population 3.5m) by the end of 2003. Three hundred forty six councils, reaching 173,000 people, have been established. Participatory processes are used to facilitate the identification of major problems faced by communities, solutions, duty bearers and their roles and responsibilities and a timeframe for action. Solutions that have been implemented by communities have included provision of ITNs, renovation of latrines and building of bridges to improve access. ITN sales since the launch of social marketing in May 2000 have exceeded 185,000. Sixty percent of community councils have selected ITNs as their preferred method of malaria prevention. The Ministry of Health (MOH) gave its approval for implementation of the community based malaria treatment component in 2001.

Following extensive flooding in southern Mozambique in 2000, the MOH, in collaboration with UNICEF and several NGO partners, distributed 200,000 ITNs free of charge to flood-affected families in conjunction with a CCD/education component. An integral part of the programme was the use of participatory approaches to increase community capacity to recognise the symptoms of malaria, identify risk groups, and to correctly use and re-treat ITNs. Participatory processes were shown to be more effective in raising awareness of malaria and its prevention than more traditional methods, such as theatre. Over 250,000 people in seven districts participated in the CCD activities. The results of a survey conducted 10 months after the distribution revealed high levels of knowledge of malaria and excellent levels of net retention. Over 97% of nets distributed were still used by the families who received them, demonstrating the effectiveness of the participatory methodologies and the fact that communities recognize the benefits of ITNs.

Lessons learned and implications

The benefits of using a participatory approach to CCD have been demonstrated successfully, in both Zambzia and Gaza provinces. Amongst populations that experienced the participatory processes, 93% cited ITNs as a malaria prevention method, compared with only 15% of a population that attended theatre presentations on malaria, which included a demonstration of ITNs. ITNs can form an important component of post-emergency rehabilitation activities when distributed in conjunction with a comprehensive, participatory education component. Concerns were raised in some quarters that ITNs would be sold to raise cash to purchase other higher priority items, however this was not the case in Gaza, demonstrating that communities consider ITNs to be valuable, high priority items.

Remaining challenges and future activities

While social marketing of ITNs has been successful in Zambzia, a province which had no prior experience of ITNs, the challenge remains to expand sales into poorer, rural communities. This is being addressed through making subsidised ITNs available through health facilities and community councils. As with all ITN programmes, a significantly greater challenge than selling nets is selling the insecticide re-treatment kits. Intensive and innovative marketing techniques are being developed and used to increase awareness of the insecticide and increase sales.

Example of instructions for Net Treatment

Note: Instructions for treating a 15 square meter bednet

Home Treatment Kits: Lessons Learned In Tanzania

Researchers from the London School of Hygiene & Tropical Medicine worked closely with a group of women in Dar es Salaam to develop a home treatment kit for nets. The process involved many focus group discussions, direct observation, pre-testing and modification. The kit included a sachet of appropriately packaged and labeled insecticide, gloves and an instruction sheet. The instructions mainly used pictures, but a few words were needed to get the essential messages across. Those who were unable to understand them or could not read asked others who could. The most difficult part of developing the instructions was describing how to vary the amount of water for nets of different sizes. It was also found that people did not describe their nets as small, medium or large, but instead related net size to the size of the bed they covered.

The most important conclusions drawn from this experience are that development of locally appropriate packaging and instructions needs careful consideration, and that packaging and instructions should be field tested before home treatment kits are made widely available.

Information to be provided on the insecticide packaging:

• The generic name of the insecticide.
• The formulation of concentration of the insecticide.
• The concentration of active ingredient in the insecticide.
• The date of manufacture and expiry date.
• The warning POISON: DO NOT SWALLOW in the local language.
• The instruction about what it is to be used for ONLY FOR USE ON MOSQUITO NETS in the local language.

Information to be provided in the instructions:

• A picture of all the equipment needed for the dipping process.
• The measuring container shown must be easily available locally or provided with the kit. If gloves are recommended they should be provided with the kit.
• Instructions that the net should be clean and dry.
• A description and illustration of how much water is required to dilute the insecticide. If more than one type of net is available locally, the instructions must provide information about how much water is required for each net type.
• A description and illustration of how to dip and dry the net.
• A description and illustration of what to do when dipping is finished, including where to dispose of gloves and empty containers, washing hands and dipping bowl with soap and water.
• A description and illustration of how to hang the net over the sleeping mat or bed, if people are unfamiliar with net use.

Field testing home treatment kits:

Field testing ensures that local people with no prior knowledge or experience can understand the instructions and use the kit safely and effectively. Initial field testing can take less than a week.

• Inform community leaders and request their permission.
• If possible identify someone who is known to and trusted by the community to explain the purpose of the field test to the community members selected.
• Select a random sample of community members. If there are large social, cultural, educational or economic differences within the community, or kits are to be introduced in rural and urban areas, you need to field test among samples representing each of these groups.
• Ask the occupants of the selected households if they wish to participate and explain what will happen. If they agree, give them a kit.
• Observe the whole process of net treatment, from collecting all the necessary equipment through to drying the net, using a structured observation checklist. Make sure the householder is not helped by anyone who has treated a net before.
• Follow up the observation with group discussions about the participants' experience of net treatment, any problems noted during observation and any concerns people have about using the kit. If problems were noted, ask people how the packaging or instruction could be made clearer.
• If packaging or instructions are revised, they should be field tested again.

The most common problems identified are:

Incorrect dilution: either using too little water, which means the solution will be insufficient to soak the whole net and insecticide distribution will be uneven, or using too much water, which means that not all the insecticide will be absorbed by the net. Including a measuring container or sachet with a marked level in the kit can help to avoid the problem of incorrect dilution, if all nets used are the same size. Where a wide range of net sizes, shapes and designs is used, getting the volume of water right is more complicated and instructions need to be more detailed.

In Dar es Salaam the net size and volume of water was expressed in the instructions in locally familiar terms. The size of a net is described according to the size of bed it would fit, and the volume of water required for each size of net is expressed as a number of soda bottles.

Inadequate mixing of the net with the diluted insecticide: if insufficient time and effort are spent kneading the net in the solution, the insecticide will be unevenly deposited on the net. Adding a further illustration to the instructions showing that the net needs to be mixed with insecticide for some time can help reduce this problem.

Using all the insecticide: if single dose bottles (20ml) are used in the kit, the instructions must make it clear that the entire contents of the bottle are required to treat one net.

Source: Malaria Programme, London School of Hygiene & Tropical Medicine

The following instructions for the K-O Tab were developed as a result of the above study:
NGAO front page, NGAO back page