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MALARIA MATTERS

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Home » Malaria Matters » Malaria Matters: Issue 5, May 1999

Malaria Matters: Issue 5, May 1999

Note from the technical editor

In order to promote the use of Insecticide Treated Nets (ITNs) there needs to be reasonably priced nets and insecticides available for people to purchase. This issue of Malaria Matters looks at different approaches to the provision and distribution of nets and insecticide. Approaches considered in this issue include:

• social marketing, as illustrated by the "KINET" article,
• Private-Public Partnerships, as illustrated in the "Ghana partnerships" article, and
• the commercial sector marketing their own products, as illustrated in the article promoting ITNs in boarding schools.

Insecticide Treated Materials (ITMs) are an important component of the Ghana National Malaria control Strategy. The Ministry of Health in Ghana (MOH), WHO and donor agencies are keen to promote their use in sub-Saharan Africa, through the development of partnerships between the public and commercial sectors. In the fall of 1998, PATH Canada and BASICS, in conjunction with the MOH, researched and developed a provisional plan for a ‘Public Commercial Partnership’ for the sustainable marketing of ITMs in Ghana. The plan was then formally presented in January 1999 to the MOH, the commercial sector and various NGOs in Ghana.

The plan presented examples of ways in which the commercial sector has been engaged in partnerships in other areas, as well as the steps involved in developing and facilitating such relationships. Research carried out in November 1998 illustrated the abundant capacity and willingness of private and public partners in Ghana to consider such a plan.

There was much discussion by public and commercial sector representatives on topics including: the availability of products, nets and insecticide, promotional strategies, demand generation, distribution, equity, trade barriers, and the local capacity to undertake such a program. The outcome of these debates was a validation of the proposed plan, and a provisional budget of $1,200,000 for a two year program was presented. The establishment of a Task Force is the next priority, as this team will have responsibility to commission and approve a detailed action plan and budget. This body would include representatives from the MOH, the commercial partners, local NGOs, BASICS, PATH Canada and the Malaria Consortium. The Task Force would be responsible for fundraising and establishing a management structure for the program. There were strong expressions of interest by several donors to support such a program.

The meeting ended with agreement on the next steps for the process:

i) the invitation of prospective members by the MOH, to join the Task Force

ii) the scheduling of the first meeting of the Task Force in April 1999

iii) formulation of program goals and objectives, and

iv) the preparation and review of a detailed action plan and full budget to the Task Force. BASICS and PATH Canada will assist in the development of the detailed plan and budget.

For more information about developing partherships in Ghana, please contact:

Dr. David McGuire or Dr. Michael Macdonald

BASICS 1600 Wilson Blvd., Suite 300

Arlington, Virginia , USA 22209

Tel: 703-312-6800

Fax: 703-312-6900

Email: dmcguire@basics.org

The KINET Social Marketing Project

KINET is a large-scale social marketing programme of insecticide treated nets in two rural districts in South-Western Tanzania (population 350,000).

Formative and market research were conducted in order to understand community perceptions, knowledge, attitudes and practice about the products that were to be marketed. "Zuia Mbu" (Kiswahili for "prevent mosquitoes") was identified as a suitable brand name for both treated nets and single-dose insecticide treatment sachets.

A mix of both public and private sales outlets are used for distribution. In the first stage of a stepped introduction 31 net agents were appointed and trained in 18 villages.

Fifteeen were shop owners, fourteen were village leaders, one was a parish priest and one a health worker. Thirty seven young people were appointed in the same villages and trained as agents for net treatment. Also involved in distribution were other institutions such as hospitals, development projects and employers.

A total of 22,410 nets and 8,072 treatments were sold during the first year. Eighteen months after program launch, 46% (N=312) of families with children under 5 reported that their children were sleeping under treated nets.

A strong evaluation component including over 50,000 people allows assessment of the long-term effects of ITNs on child health and survival, anemia in pregnancy, as well as the costs of the intervention. The evaluation is based on cross-sectional surveys, case-control and cohort studies.

KINET CONTACT INFORMATION

Ms. Joanna Schellenberg Ifakara Health Research & Development Centre P.O. Box 53, Ifakara, Tanzania

Promoting ITNs in Boarding Schools

By Ato Harry Brew, Osbourne Harold Brew, and Yaw Berko

Malaria is a leading cause of death and disability in Ghana. As part of the malaria control strategy, the Ghana National Malaria Control Program recommends that children attending boarding schools use treated nets. Though school age children are not most at risk of dying from malaria, they still suffer from debilitating attacks. They are also the future parents of young children who are at risk of dying.

One net importer, HUGE Limited of Accra and its associate Cefgrains Company Limited, are spearheading the use of ITNs in boarding schools in Ghana. Starting in the Central Region, over 1000 new bednets were sold and 2200 old and new nets were treated. HUGE Limited has also supported the launching of a malaria awareness and control project in the Volta Region, sponsored by the Lions Club of Accra. Nets were imported from Kenya. Cyflutherin (both single dose and one-liter bottles), was imported from Bayer, in South Africa, and used for net treatment.

The success of the project in the Central Region can be attributed to efforts made to sensitize the public. Malaria brochures were distributed beforehand to all the schools throughout the Central Regional Educational Directorate. In addition, there were numerous talks to Parent Teacher Association and students to promote ITNs. This outreach initiative is being expanded to more remote regions that have also been sensitized to the benefits of ITNs.

For more information, please contact:

HUGE Ltd.

E58 Avodire Street, Atomic Hills Estate 

P.O. Box 674, Achimota, Ghana Tel. 028 21 3392

Public-Private Partnerships and ITNs: What Each Partner Has to Offer

Over the past decade, the role of ITNs in preventing malaria has become well known as a cost effective intervention, especially in sub-Saharan Africa (SSA). ITN research has suggested that although effective, new and innovate ways to promote and distribute ITN use and re-treatment are needed, the public sector cannot do it alone. A recent study conducted by PATH Canada* examined the perceived respective roles of the private and public sectors in increasing the use of ITNs. Three-way partnerships between NGOs, commercial sector, and government were studied to identify what each partner can offer.

Much of the challenge of introducing ITNs in SSA arises from the necessity of implementing equitable, lasting, and sustainable collaborative programs. Working independently, each group faces barriers that impede widespread ITN distribution. For example, governments cannot afford to supply ITNs for all people who are at risk; the public sector does not have the capacity to manufacture and sell goods; and the commercial sector is loathe to invest in the costly and risky work of creating a market. However, by pooling resources, expertise and creativity, the strengths of each partner can be maximized. Governments can affect policy, the commercial sector can ensure that the product is available to the public, and NGOs can play a large role in health promotion and demand generation.

The following chart provides a comparison of the qualities, strengths and limitations that each partner brings to the table. By creating a dialogue between the partners, and exploring these strengths and weaknesses, a plan can be developed to work together, and increase the use of ITNs by the most vulnerable population groups.

Developing Partnerships between public and commercial sectors in Ghana

Summary of Insecticide Treated Bednets and Curtains for Malaria Control

By C. Lengeler,Cochrane Library Issue 1, 1999

OBJECTIVES

The effectiveness of insecticide treated bednets or curtains in preventing illness and death in malarious areas was reviewed using the Cochrane Collaboration framework. All randomized controlled trials (published or unpublished) using either insecticide treated bednets or curtains with a sufficient dose of a suitable insecticide were reviewed. Trials using alternate allocation methods that appeared unbiased were also included.

RESULTS

A total of 18 trials met inclusion criteria. The overall reduction in mortality (i.e., the protective efficacy, PE) was 17% in comparison with control participants not using nets, and 23% in comparison with untreated nets. When impregnated nets were compared with untreated nets or no nets (pooling all trials), the overall estimate of PE was 18%.

A trend for the PE of ITNs to decrease with increasing transmission intensity was detected (p<0.03). The summary risk difference (expressing how many lives can be saved for every 1000 children protected) was 6 per 1000 children protected per year. ITNs reduced substantially the incidence of mild malarial episodes. In areas of stable malaria, PE was 48% when the control group did not have any nets and 39% when the control group had untreated nets. A consistent impact was also found in areas of low transmission against both P.falciparum and P.vivax. Impact on P.falciparum and P.vivax prevalence was modest but significant for certain sub-groups, but not all. In areas of stable malaria, PE=5% when the control group did not have any nets and PE=10% when the control group had untreated nets. There was a modest impact on high P.falciparum: PE=24% when controls had no nets, PE=20% when controls had untreated nets.

CONCLUSIONS

ITNs have been shown in trials to reduce overall mortality by about 20% in sub-Saharan Africa. For every 1000 children protected, about six lives can be saved per year in the age group 1-59 months. ITNs also show substantially reduced clinical episodes of mild malaria from both P.falciparum and P.vivax infections.

THE IMPLICATIONS FOR PRACTICE

Given that there is strong evidence that ITNs can reduce overall mortality by 20%, and that the impact of the use of ITNs on clinical episodes of mild malaria is considerable, there is a need to promote the large-scale application of this control tool in malaria control programmes in endemic areas. This view was endorsed at a recent WHO meeting. In high endemicity areas, mortality should be monitored carefully in the frame of large-scale programmes in order to clarify issues of long-term impact.

SOME RESEARCH AREAS THAT NEED FURTHER WORK

• To determine in different transmission situations how much of the impact of ITNs measured in controlled trials is preserved under programme conditions;
• To examine how impact varies with the coverage rate of people sleeping under nets;
• To investigate further the effectiveness of untreated nets;
• To test the hypothesis that impregnated nets reduce acquisition of immunity in high transmission areas.

For more information, please contact:

Swiss Tropical Institute, Department of Public Health, and Epidemiology.

P.O Box (no #). 4002 Basel Switzerland.

Tel: (011-41- 61) 284 8221

Fax: 011-41-61 271 7951

Treating a net, as simple as 1, 2, 3!

This is a technique known as "bag dipping and treatment". This is remarkably fast and avoids virtually all contact with insecticide, without wearing gloves. Most commercial manufacturer´s nets are supplied in plastic bags, but A-Z Textiles Ltd. in Tanzania have begun to supply theirs in carrier bags, which is a wonderful opportunity to encourage nets to be treated.

Step 1: Put a clean dry net into a carrier or other plastic bag (if the net is new, shake it out first).

Step 2: Make a solution of water and insecticide in a jug and mix well. The amount of water and insecticide depend upon the type of net and insecticide you are using. (This technique works best when just the right amount of water is used so that there is no mixture left at the bottom of the bag when all three steps are finished). Pour this mixture onto the net in the bag.

Step 3: Seal the bag and hold it firmly then knead the net and solution inside the bag.

Quick tip: If there is a small hole in the bag, tie a knot over it!

Suggested reading

INSECTICIDE TREATED NET PROJECTS: A HANDBOOK FOR MANAGERS

By Desmond Chavasse, Catherine Reed & Kathy Attawell

Insecticide treated mosquito nets have been widely hailed as a simple and cost-effective technology for improving child health. Since the early 1990´s many operational projects have been implemented with varying degrees of success. The main lesson learned is that although the technology may appear simple, implementing programmes that survive beyond the short term is not. There is no blueprint that can guarantee a successful project, but there is a wealth of operational experience from previous projects which have adopted a wide range of implementation strategies. This handbook is designed to be a practical decision making tool for project managers. It covers the essential elements of planning, implementing and monitoring treated net projects, and is illustrated with examples from more than 30 projects in 16 countries. Through this handbook, project managers can start from a position of relative strength, based on past experience, and can rapidly evolve their own implementation strategies appropriate to local needs.

COST FOR ITN PROJECTS HANDBOOK

UK 7.00 inc. postage and packaging for those in industrialized countries

FREE for those who live in a developing country and who receive a local currency or the equivalent of a local salary.

* Prepublication advance purchase of 15 copies or more receive a 15% discount.

TO ORDER

Please enclose a cheque / money order in a stamped envelope and mail to:

Malaria Consortium, ITN Projects: A Handbook for Managers

P.O. Box 121, London SE 20 8ZQ

For inquiries please contact:

Stephanie Thorpe, Malaria Consortium.

Tel: +44 (0) 171 927 2439 

Fax: +44 (0) 171 580 9075 

Email: s.thorpe@ishtm.ac.uk