Global Framework for Scalingup Insecticide Treated Nets Challenges and Prospects

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Global Framework for Scaling-up Insecticide
Treated NetsChallenges and Prospects

• Inter-country Workshop on Scaling-up ITN
  Implementation for Control of Malaria other
• Vector-borne Diseases in EMR Abha, Saudi Arabia,
  October 18 - 20, 2003
• Mohammadou Kabir Cham, HTM/RBM Department, Geneva

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Overview of Presentation

• Strategic framework
• Shared vision
• Concepts/elements
• Considerations
• Unfinished jobs
• Use in vector-borne diseases

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Efficacy

• EFFICACY (large-scale trials)
• Substantial impact on child mortality
• (1-59 months) in Africa overall reduction of
  19 in child mortality
• equivalent to 6 deaths averted per year and per
  1000 protected children
• With more than 80 million children under 5 at
  risk in Africa 500,000 deaths could be saved
• Substantial impact on severe disease (60
  reduction)
• Substantial impact on mild disease episodes (50
  less clinical episodes)
• leading to HH savings and less over-crowding in
  health service

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Effectiveness

• EFFECTIVENESS (large-scale programmes)
• 27 reduction in childhood mortality among ITN
  users in a high transmission area, Tanzania
• highest in infants
• 63 reduction in anaemia
• No indication that there is a delayed mortality
  effect

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Effectiveness

• National Impregnated Net Programme, The
• Gambia
• 83 net treatment rate
• 77 U5s, 78 WCBA reportedly sleeping under
  treated nets
• 25 overall childhood mortality
• 59 less episodes of uncomplicated malaria in ITN
  users

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The Need

• ITNs - one of the four key RBM approaches
• Current status
• many local, time-limited projects
• lack of co-ordinated action
• Need for a balance between equity and
  sustainability
• public-private partnership

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Challenges

• Increasing coverage
• increasing availability of ITNs
• expanding supply, distribution and demand on a
  large scale
• Barriers
• supply - TTs, regulatory issues, inadequate
  distribution systems
• demand - price and affordability, promotion and
  marketing
• Low insecticide retreatment rates

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ITN Use

• Leads to reduced
• vector survival
• sporozoite rate
• incidence of infection in humans
• prevalence in humans
• reservoir of infections in humans
• long-term effects may prove much to be
  substantially greater than short-term effects

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The Strategic Framework

• Intended for use by country level RBM
• partnerships
• development and co-ordination of
• national ITN strategies
• guide donors supporting ITN
• strategies

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A Shared Vision for the Future

• Most people buy nets at unsubsidized prices
• Competition in the market
• keeps net prices low
• quality high
• good penetration to remote rural areas
• Government provides enabling environment (generic
  demand creation TT barriers removed
  insecticide registration streamlined)
• Providing ITNs to most vulnerable
• preferably separate subsidy and goods

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Elements of the Framework

• Variety of actions and activities will be
  necessary
• some to be sustained indefinitely
• others essentially temporary
• some to be carried out by public sector, while
  others by NGOs
• Relationships between roles and responsibilities
  
• appropriate balance between subsidized approaches
  and commercial market development
• Relationship will evolve over time as context
  changes

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Two Key Concepts

• Subsidies that are sustained and targeted to
  vulnerable groups
• focus resources, maximize public health benefits
• methods of targeting
• targeting also needed for
• Growth of commercial sector
• enabling environment
• demand creation

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National Co-ordination

• Mechanism to co-ordinate and catalyze scaling-up
  ITNs at
• national level by
• creating strong political support
• advocacy and soliciting human and financial
  resources
• lobbying removal of tax and tariff barriers
• facilitating negotiation
• co-ordinating promotion
• planning mechanisms for targeting subsidies
• monitoring and evaluation for continuous
  improvement
• agenda-setting for operations research

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Targeted Subsidies for Public Health Benefits

• Who should benefit, how can they be reached?
• socio-economic definitions
• geographical definitions
• biological definitions
• Vouchers
• easier to distribute, gives choice to recipient
• stimulates commercial trade
• leakage
• Selling subsidized goods
• costly
• loss of subsidy
• inhibition of commercial trade

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Other Subsidized Distribution Systems

• Complex emergencies/natural disasters
• free distribution justified to provide immediate
  relief
• geographical targeting
• Revolving funds
• difficult as a scaling-up strategy

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Supporting and Stimulating Commercial Sector

• Enabling environment
• removal of tax and tariff barriers
• streamlining insecticide registration
• Demand creation
• generic advertising
• Market priming
• short-term supply, long-term demand creation
• evaluation in terms of impact on commercial
  sector, not subsidized sales
• branding
• Unsubsidized trade will NOT move in UNTIL
  subsidized
• goods are withdrawn!

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Considerations

• Nets insecticides - commodities as much as
  public health products
• allow great flexibility in implementation
  strategies
• Potential commercial retail outlets outnumber
  health facilities by at least 101
• No currently identified serious threats to
  national scaling-up ITN interventions in endemic
  countries

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Unfinished jobs.

• Consensus on long-term vision, but
• how to target?
• when and how to withdraw market priming?
• other subsidy mechanisms
• indicators especially market monitoring
• LLINs (insecticides)
• promotion and dissemination strategies

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Potential Application

• Leishmaniasis largely benefiting from mosquito
  control approach
• African trypanosomiasis tsetse fly traps
• Dengue house screening, jar lids, curtains..
• Lymphatic filariasis combined approach with
  malaria in rural areas, use in urban settings
• Chagas disease control of transmission by non
  domestic vectors

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Potential Application

• Use of long lasting treated clothing for
  travellers protection, typhus, synanthropic
  flies
• Mites (treated bed sheetings)
• Plastic sheeting and treated blankets for
  emergency situations
• New materials in novel housing technologies
• Possible use of this technology for controlled
  release larvicide formulations

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There is hope for winning the battle against
malaria