Malaria Matters: Issue 6, December 1999

This issue of Malaria Matters Featuring Netting News was made possible by generous support from: AgrEvo Environmental Health. They can be reached at: P.O. Box 80 03 20, D-65926 Frankfurt am Main, Germany.

Rolling Back Taxes

Dr David Nabarro, Manager of the Roll Back Malaria cabinet project at WHO, called for a rationalization of taxes and tariffs on mosquito nets and insecticides at the opening night trade show of the 2nd International ITN Conference (held in Tanzania 11 - 14 October). Reducing or eliminating taxes and tariffs on ITNs and insecticides would bring prices down and help increase the availability of these essential malaria prevention tools in endemic nations. Nabarro's goal is to achieve positive results in numerous countries within the next six months. Representatives from the World Bank also supported this goal.

Tanzania has the strongest commercial manufacturing base for mosquito nets in Sub-Saharan Africa. This distinction has largely been due to the favourable tax and trade environment developing in the country since 1993. First the sales tax and now the value-added tax (VAT) has been removed on locally produced, as well as imported, nets.

The Tanzania story demonstrates the importance of a strong and well-coordinated local lobby. Manufacturers, local and international NGOs, and the Ministry of Health campaigned hard in Tanzania and succeeded. Many lobbies in other countries have yet to achieve the same results, a situation often attributed to a lack of political will both nationally and internationally. WHO and the World Bank are taking up this issue at the highest levels to gain political support on a global scale. However, a lesson learned from Tanzania is that good guidance is also necessary locally to help develop new legislation.

Each country is unique. Some have a multitude of nets already on sale, and some have very few. Some need to import nets, some have a local supply. Taxes differ from country to country and can be quite complicated. Lobbyists should make sure that all the types of applicable taxes are identified (import, customs, tariffs, value-added, sales) and for each phase of the products (yarn, netting, finished nets, insecticides). It is important to understand how each phase of the product is classified (medical or health product, luxury good, textile, chemical) because the applicable tax could be different depending on its classification.

The Harvard Institute for International Development and the World Bank will be available to advise on these issues. To coordinate efforts we would suggest that anyone involved with negotiations at a country or regional level contact John Paul Clark with a brief summary of their activities and successes to date or with requests for support on these issues. He can then assess who might be the appropriate advisers from HIID and/or the Bank.

RBM contact:

John Paul Clark, Team Leader, Roll Back Malaria Secretariat, World Health Organization
20 Avenue Appia 20, office 6010, CH- 1211 Geneva 27, Switzerland
Tel: 41-22-791-3781
Fax: 41-22-791-4824
Email: clarkj@who.int

A Monitoring Framework for an ITN project in Zambia - Lessons Learned

The Churches Medical Association of Zambia (CMAZ) has been promoting ITNs through a pilot project for three years. One aspect of this project has been focused on the development of a monitoring and evaluation strategy and methodology for the ITN activities. Within this strategy was the promotion of ITNs through the Primary Health Care program. The first step was strategic planning, used to develop aims and actives and to decide on indicators which could be used to evaluate progress using the following steps;

• Identify programme goals and objectives
• Identify monitoring indicators and sites
• Define monitoring methods and timing
• Analyze and interpret monitoring data
• Use monitoring and evaluation information to improve programme implementation

 

AIMS	OUTCOMES	INTERPRETATION	PROPOSED ACTION
1) Reduce malaria incidence and mortality from malaria	Hospital record data not easily interpreted due to no case definitions, inconsistent performance of malaria smear, no methods of accounting for variables eg: changing weather	Very difficult, if not impossible, to accurately measure impact on malaria incidence/mortality	Re-evaluate utility of this indicator; impact evaluation may best be left to MOH surveillance programmes
2) Reduce net and insecticide costs	Cost of bulk acquisition of nets and insecticide were $6.00/net for CMAZ; taxes and tariffs added an additional $4.50/net; nets and insecticide were sold to hospitals for $6.00/net; hospitals sold to the community for $4.00/net	Subsidies prevented full cost-recovery; there is some evidence that subsidized nets were primarily purchased by those who could afford to pay more and not those at whom the subsidy was aimed	Remove tariffs and taxes; remove heavy subsidies
3) Increase hospital ITN usage	10-12 hospitals and 2 rural hospital clinics (approx. 15% of CMAZ institutions) are currently using ITNs; ward coverage of patients is quite variable with one hospital concluding that ceiling fans and screened windows preclude need for ITNs	Hospitals will not all have the same requirements for ITNs	Reevaluate hospital needs for ITNs
4) Increase households dipping and using ITNs	Follow-up data has revealed household net ownership of nearly 50%, BUT redipping practices are virtually nonexistent	Nets are usually easy to market and sell; insecticide is not	Need to have separate net sale and redipping programme and monitoring objectives
5) Increase pregnant women and under 5s sleeping under ITNs	Difficulties with random cluster survey technique resulted in inaccurate data from one hospital; follow-up survey at other hospital revealed 25% of under 5s and 36% of pregnant women sleeping under nets	Although numbers of under 5s and pregnant women sleeping under nets were encouraging, these were likely not treated nets	Need to review random cluster survey techniques; need to find ways to promote and improve redipping practices

Dr Pierre Plourde of PATH Canada worked with CMAZ on this process, and after one year an evaluation of CMAZ and the hospital activities was carried out, the results are summarized in the preceding table: These results led to a review of the aims of the project, and the activities that must be pursued to meet their objectives. The review also helped demonstrate the importance of basic record keeping. Two particular problems were highlighted. First was the need for an easier and better defined way of choosing a sample for quantitative surveys, since no common methodology had been used. The second point was the need to review indicators as most of the original ones were concerned with 'outcomes' and none critically address the "process". Monitoring and evaluation may be challenging, but they are essential to document progress and assess the project impact through failures and successes. The cost of monitoring and evaluation need not be expensive; in the CMAZ exercise the costs were a small fraction of the net retreatment program.

In the Field - and in the shops!

WHOPES - Talking to the Experts

The WHO Pesticide Evaluation Scheme (WHOPES) is vitally important in ensuring that products used in health programmes are thoroughly tested before they are launched on to the market and to ensure that they will actually do the job intended. It also ensures that products are properly packed and labeled, and most importantly that the product supplied complies with the World Health Organization specifications, which is laid down as part of the evaluation procedure.

At the recent 2nd ITN Conference in Dar es Salaam, Dr Zaim of WHOPES recommended the use of non solvent based insecticide formulations for treatment of mosquito nets because of their better safety profiles (for example: capsule suspension, emulsion, oil in water, suspension concentrates or water dispersible tablets). In emulsifiable concentrates (EC's) the insecticide is mixed with a solvent, which increases the risk of toxicity if they are accidentally swallowed or splashed onto the skin, and they are smelly and flammable. Permethrin is the only EC formulation which is still in the list of WHOPES recommended insecticides for treatment of mosquito nets. However for their supply over the counter (OTC), child-proof packaging should be mandatory. Moreover, the OTC supply of high concentration permethrin (>10%) should be avoided.

Business Sense and Common Sense

Bednets are only effective in reducing malaria morbidity and mortality when they are treated with insecticide. In Tanzania the use of treated nets is increasing, largely due to the availability of good quality, cheap, mass produced nets. It is therefore encouraging to hear that Cyanamid is partnering with A - Z Textiles, a large net producer, to sell nets and net treatment kits in the same carrier bag. The sachets of alphacypermethrin 6% (Fendona) come with instructions in Kiswahilli and English. These "Safi nets with Fendona" will be marketed in urban and rural Tanzania through existing retail outlets. Though net treatment is far from common in Tanzania, the PSI social marketing project has done much to start a new tradition with their promotional campaigns. This is a commercial venture but it is hoped that it will both benefit from and compliment the existing public sector projects in the country.

Insecticide for net treatment: the private sector seen moving in Zimbabwe

By Christian Lengeler

The EcoMark company of Zimbabwe chose a Roll Back Malaria meeting, earlier this year, to launch KO-Tab deltamethrin tablet, one of the new generation of pyrethroids specifically designed and formulated for the treatment of netting materials. This event was remarkable for a number of reasons.

Firstly, it resulted entirely from the initiative of a company specializing in Human, Animal and Environmental health which recognized the business opportunity offered by this new product. Such companies (as well as the main insecticide manufacturers) need to be motivated in all the malaria-endemic countries in order to move into the market with appropriate and reasonably priced products. Secondly, this initiative was based on a number of business links developed by the company over the years into an effective web of partnerships, including two large employers (with a total work force of over 10,000). Ecomark has also collaborated with, and benefited from the ITN social marketing project run by PSI marketing nets and insecticide in rural areas of Zimbabwe.

Secondly, the minister of health himself attended the launch and expressed a strong support for this initiative. This willingness to cooperate was also echoed by other bilateral and multilateral donors. While each country will have to develop its own form of private-public partnership on the large-scale implementation of insecticide-treated mosquito nets, this example illustrates the new options, varying approaches, and new opportunities offered by expanding beyond traditional national malaria control programmes.

Suggested reading

Second International Conference Report

The Second International Conference on Insecticide Treated Nets was held at the Sheraton Hotel, Dar es Salaam, 11-14 October 1999. The Conference was hosted by the Government of the Republic of Tanzania, the Malaria Consortium, UNICEF, USAID and WHO, and received financial support from a wide range of donors, private sector companies and technical agencies. The conference, attended by over 200 participants representing ministries of health and other government departments, donor agencies, research institutions, the private sector and NGOs, has been hailed a success by all - much was learnt about the latest approaches to widescale implementation of ITNs and many new partnerships were forged. For a copy of the official Conference Report, due out in January 2000, contact:

Jenny Hill, Malaria Consortium. Liverpool School of Tropical Medicine
Pembroke Place, Liverpool L3 5Qa, UK
Tel: 44-151-708-9393
Fax: 44-151-707-1673
Email: j.hill@liv.ac.uk

Guest website

Malaria Educational Site

A bilingual CD-ROM is available, free of charge for educational or medical institutions with limited internet access. For more information please contact Graham Icke at: grahicke@rph.health.wa.gov.au