| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
 |
ABSTRACT |
 TOP ABSTRACT INTRODUCTIONITNS: WHAT VISION?ITN UPSCALING: ONLY WITHIN...DISTRIBUTION OF FREE NETS...DEVELOPING THE COMMERCIAL SECTOR...SUMMARY AND CONCLUSIONSREFERENCES |
|---|
|
INTRODUCTION |
|
TOPABSTRACTINTRODUCTIONITNS: WHAT VISION?ITN UPSCALING: ONLY WITHIN...DISTRIBUTION OF FREE NETS...DEVELOPING THE COMMERCIAL SECTOR...SUMMARY AND CONCLUSIONSREFERENCES |
|---|
500,000 child deaths each year,1 a major reduction in suffering and economic losses, and a crucial contribution toward the achievement of the millennium development goals. How to achieve national scaling up of ITNs sustainably and with the best operational and financial efficiency has been the subject of many debates.3,4 Here we aim to contribute to one core element in this debate: should high-risk beneficiaries be expected to pay for their ITNs or should this be considered an essential public health good to be provided for free in a way similar to childhood vaccines or other routine interventions? We will focus this discussion on the provision of ITNs to defined high-risk groups, because this is where most public health gains can be made. In doing so we are not addressing the fact that ITNs are desirable for other age groups and that a high coverage with ITNs in the general population leads to an overall reduction in malaria transmission. This "mass effect" is well described in trial situations,5,6 and it does substantially enhance protection to both net users and non-users (GK Killeen and others, unpublished data).
Currently, a number of major distribution and financing models have been implemented, and they have provided a good body of global experience: 1) focus on commercial sector development (e.g., USAID-NetMark Project countries, www.netmarkafrica.org); 2) free distribution through public health facilities (e.g., Eritrea7); 3) free distribution in the frame of measles vaccination campaigns (12 SSA countries thus far); 4) social marketing (e.g., Kenya); and 5) integrated approaches—more and more found in all countries because "pure" models are becoming rare (e.g., Ghana, Malawi, Tanzania). Unfortunately, the systematic description of these projects and their experience is beyond the scope of this paper.
The existing RBM framework for ITN upscaling prepared by the Working Group on Scalable Vector Control (RBM-WIN) outlines recommendations for tackling national upscaling on the basis of the existing experience.8 Among the many considerations that are important for supporting large-scale ITN deployment, there is one that is central to our debate: the need to have rapid gains in coverage in all endemic countries, while at the same time, setting up systems that will ensure long-term availability (quick wins versus long-term sustainability). In addition, the impact (positive or negative) on the existing health system needs to be taken into account, but this aspect will not be discussed here. Finally, it is also necessary to outline a clearer vision for the future of ITNs as part of this debate.
|
ITNS: WHAT VISION? |
|
TOPABSTRACTINTRODUCTIONITNS: WHAT VISION?ITN UPSCALING: ONLY WITHIN...DISTRIBUTION OF FREE NETS...DEVELOPING THE COMMERCIAL SECTOR...SUMMARY AND CONCLUSIONSREFERENCES |
|---|
An important issue is whether vaccines and ITNs are sufficiently similar that an EPI-like approach could be considered. Both target well people and not sick patients. Both can be delivered in campaigns, and in the case of the oral polio vaccine, with minimally trained community workers. Both interventions target the same priority population—children younger than 5 years of age. An additional public health advantage of ITNs is that they are available to all children who use the sleeping space they cover, not just the child to whom the net was "assigned." Table 1
compares key features of LLINs (improved ITNs that do not need to be retreated) and the commonly used pentavalent childhood vaccine (diphtheria-tetanus-Polio plus Haemophilus influenza and hepatitis B). Compared with the pentavalent vaccine, LLINs have a similar cost per death averted, while targeting largely the same population. If LLINs offer the same public health advantages as vaccines, perhaps they should receive the same approach to public financing and program management as vaccines.
|
ITNs as a public good might be a moot point because there are neither systems in place nor long-term funding commitments to make them widely and indefinitely available. USAID-funded research in Ethiopia, Ghana, Mali, Nigeria, Senegal, and Uganda has shown that ITNs distributed through public sector channels are often sold for prices that approach commercial levels and often leak into the marketplace, where they are resold to higher-income families (www.netmarkafrica.org/research/index.html). Is this a good use of taxpayer money? At the same time, in Mali, one of the world’s poorest countries, > 70% of all households own nets that were obtained through existing commercial outlets. These nets are often not treated with insecticide, but they do offer nevertheless a good level of protection.1
ITNs have been effectively distributed for free through vaccination campaigns targeting the most vulnerable. This is a solid strategy to target children and should be expanded. However, this strategy ignores children who are born after a campaign and die before the next one. And, what about the older children in the family, or the wage-earners, all of whom are vulnerable to malaria and are left exposed? If they fall ill, the medical expenses, together with missed work and school, create an emotional and financial burden on the family and community.
Although we need to provide ITNs to those who cannot pay, we cannot make delivery of these products totally dependent on systems and funding sources that have repeatedly failed the people of SSA for the past 50 years. We cannot tell people to simply avoid mosquitoes before the next campaign reaches them. Mothers and fathers should have the possibility to purchase an inexpensive ITN through the same commercial sector that currently provides the vast majority of their goods and services. Uganda is a case in point, where promises by the public sector to distribute 1.8 million ITNs almost 3 years ago have not resulted in one person receiving a net. In the meantime, the commercial sector has sold > 3 million nets—unfortunately largely untreated because of the lack of a clear national policy. In the eight NetMark countries, retail sales have exceeded 19 million ITNs and 31 million untreated nets since 2002. In addition, African and international businesses have invested more than $44 million in country programs.
As countries attempt to rapidly scale up ITN coverage, they cannot neglect the short- and long-term benefits of using commercial channels as a complement to well-targeted distribution of free or nearly-free nets to the poorest of the poor. Commercial ITNs provide an option to families facing the threat of malaria. Taxpayers and the beneficiaries in developing countries need to look beyond this approach to ensure that, in pursuing "quick wins," we do not leave current and future generations vulnerable.
|
ITN UPSCALING: ONLY WITHIN AN ENABLING ENVIRONMENT |
|
TOPABSTRACTINTRODUCTIONITNS: WHAT VISION?ITN UPSCALING: ONLY WITHIN...DISTRIBUTION OF FREE NETS...DEVELOPING THE COMMERCIAL SECTOR...SUMMARY AND CONCLUSIONSREFERENCES |
|---|
First, countries need to take a programmatic and national perspective, away from a project approach. From the onset, the strategies and activities need to be designed with national program size in mind, and most importantly, a strong government commitment at all levels.
Second, many actors will be relevant for planning national ITN upscaling, including government ministries, NGOs, researchers, bilateral and multilateral agencies, and other identified stakeholders. Strong stakeholder coordination is essential for the maximization of both process and impact, as shown, for example, in the case of Tanzania10 or in other endemic countries.9 This coordination process needs to be underpinned by a strong government leadership from within the country.
Third, it is essential that the government’s commitment extends to developing a supportive legislative environment, including regulations for nets (requiring them to be of a certain quality and hopefully soon requiring them to be LLINs) and insecticide (which is needed to make use at household level possible), favorable trading conditions, and the removal of taxes and tariffs on all net and insecticide products (as agreed by all African governments in Abuja in 2000).
Finally, large national programs need a strong management structure (financial, logistical) supported by all national stakeholders, in the same way as EPI or other major public health programs. Good management, in turn, maximizes chances for ongoing funding of key activities at the required level—from national and international sources.
|
DISTRIBUTION OF FREE NETS THROUGH PUBLIC CHANNELS |
|
TOPABSTRACTINTRODUCTIONITNS: WHAT VISION?ITN UPSCALING: ONLY WITHIN...DISTRIBUTION OF FREE NETS...DEVELOPING THE COMMERCIAL SECTOR...SUMMARY AND CONCLUSIONSREFERENCES |
|---|
Initial attempts at integrating EPI and ITN delivery have been encouraging, although largely restricted thus far to co-distribution during measles catch-up vaccination campaigns. Such campaigns started in Africa in 2000—the same year as the Abuja Declaration. Although ITN coverage has lagged well below the Abuja target of 60%, by 2006, > 200 million measles vaccinations had been delivered. Since 2004, > 18 million ITNs (mostly LLINs) have been delivered during measles vaccination and other campaigns (Table 2).
|
). Hence, mechanisms must be put in place to ensure the continuous provision of ITNs either for free or at very low cost to these children and their mothers. This can either be done through free distribution of LLINs or through some kind of a voucher scheme, allowing the project to devolve the complex task of supplying nets to the commercial sector.10
|
A serious problem at present is the lack of evidence on how to proceed from a campaign mode to a continuous delivery mode. Wider adoption of free distribution of ITNs through EPI or other clinic-based approaches has been limited thus far to Eritrea,7 whereas in Malawi, a co-payment of US$0.6 was requested.14 To some extent, this topic has become entangled in the debate over whether ITNs should be free to all women and children. During vaccination sessions, all services must be free to avoid giving mothers the false impression that they may be paying for the vaccine, which might prevent the poor from coming back for subsequent vaccinations. Although sustainability remains a complex issue, there is at least a high level of agreement that ITNs given out during a vaccination contact will be used properly when supported by adequate education and promotion. If LLINs can be given out, the effect is maximized. Clearly, the massive free distribution of the nets raises substantial logistical issues, and there is empirical evidence that it might undermine the development of the commercial market (K Hanson and C Jones, unpublished data). A solution to both problems is the use of vouchers, which ensure a very inexpensive net to the beneficiary, while boosting the development of the commercial sector.10,13,15 In Tanzania, high-value vouchers (US$2.50) are now given to pregnant women during their first antenatal care visit, as well as to the mothers of children coming for measles vaccination at 9 months. In addition, a campaign to give a free LLIN to every child younger than 5 years of age as a one-time "catch-up" event is also planned.
|
DEVELOPING THE COMMERCIAL SECTOR FOR ITNS |
|
TOPABSTRACTINTRODUCTIONITNS: WHAT VISION?ITN UPSCALING: ONLY WITHIN...DISTRIBUTION OF FREE NETS...DEVELOPING THE COMMERCIAL SECTOR...SUMMARY AND CONCLUSIONSREFERENCES |
|---|
Volume. The private sector has the potential to get ITNs distributed nationwide in most countries; from our observations, it can do so far more efficiently than the public sector. Well-established businesses in communities are more convenient and often more reliable than public clinics, where people must wait in long lines and be subjected to impersonal treatment, only to be handed an ITN that may or may not be the one they want. Private sector outlets provide consumers with choice in terms of brand, size, color, and price, so that each family can decide how and when to best meet its own needs. The private sector provides families with the opportunity to protect all of their members rather than limiting distribution to pregnant women and children younger than 5 years of age during irregular campaigns.
Cost. Distribution through the private sector reduces the cost of distribution of ITNs to donors and governments, allowing them to focus their limited resources on the poorest of the poor and the most vulnerable. Although the cost of distributed ITNs to donors can be as little as US$3.00–5.00,14 additional costs of education and promotion are often not tracked or revealed, although they are essential for ensuring use and sustainability. Development of the private sector through partnership results in significant commercial investment, thereby increasing the impact of each dollar invested by the public sector. As for the cost to consumers, increased competition can result in improved products, increased availability, lower prices, and more choice.
Sustainability. Although there are huge financial resources being committed to ITN procurement today, there is always a danger that these investments will not continue for many years. While resources are available, we have a responsibility to build local capacity to deliver ITNs and educate populations about their effectiveness. There have been numerous examples in the past of donor-funded free distribution of products such as oral rehydration solution and contraceptives that have not been sustained. In the absence of private sector delivery, the end of funding means the end of options for vulnerable people.
On balance, the advantages to working with African businesses to build sustainable distribution networks for ITNs far outweigh the challenges and disadvantages. Building commercial distribution for ITNs in Africa, in coordination with targeted subsidy programs, is an essential element in the fight against malaria.
|
SUMMARY AND CONCLUSIONS |
|
TOPABSTRACTINTRODUCTIONITNS: WHAT VISION?ITN UPSCALING: ONLY WITHIN...DISTRIBUTION OF FREE NETS...DEVELOPING THE COMMERCIAL SECTOR...SUMMARY AND CONCLUSIONSREFERENCES |
|---|
This is a considerable challenge, the difficulty of which is attested to by the fact that it has rarely been achieved as of 2007. Our review with a double focus confirms the widely held view that no single approach is likely to bring the perfect solution to such a complex problem. In this light, the best way to achieve sustainable malaria prevention is to mobilize all available resources and partners through a coordinated strategy based on the local context. There is also an urgent need to learn more about large-scale program experience and debate the findings.
There is very clearly a need for a rapid catch-up strategy because African rates of ITN use have remained too low for far too long. More than 10 years after conclusive proof of their efficacy, ITNs are used on average by < 10% of high-risk individuals in endemic areas. This is simply unacceptable. Mass distributions associated with measles vaccination or any other strategy of "catching-up" provide a unique opportunity to rapidly scale up ITN use.
At the same time, there is a need for additional approaches to 1) provide continuous provision of long-lasting ITNs for newly pregnant women and their babies and 2) provide protection to the rest of the population. In the absence of sufficient long-term funds to provide free nets to all, targeted subsidies will continue to be an important tool to achieve the first objective, either through the direct distribution of a long-lasting ITN (usually through clinics) or through the use of publicly funded vouchers redeemable through retail outlets. To achieve objective 2, a strong and competitive commercial sector for nets seems to be a good strategy.
With a minimum of planning and good public promotion campaigns, these strategies can co-exist and even re-enforce each other. This leads to a clear vision, shared widely within the international health community: "All people exposed to malaria in Africa will own and use mosquito nets, either as long-lasting insecticidal nets or regularly re-treated. Those most vulnerable to malaria will not be excluded from owning an ITN due to cost. Through public sector subsidies, vulnerable groups will be able to obtain ITNs at little or no cost to them through public channels (e.g., EPI or ANC), sometimes in the form of a voucher and sometimes in the form of the ITN itself. Within the commercial market, prices will be kept as low as possible by economies of scale and competition at all levels."8
Finally, governments will help by providing an "enabling environment" and the international community should ensure appropriate funding of sound programs.
Received February 9, 2007. Accepted for publication May 1, 2007.
Acknowledgments: The authors thank the members of the RBM Working Group on Scalable Vector Control (WIN) for many stimulating discussions.
* Address correspondence to Christian Lengeler, Swiss Tropical Institute, P.O. Box, 4002 Basel, Switzerland. E-mail: Christian.Lengeler{at}unibas.ch 
Authors’ addresses: Christian Lengeler, Swiss Tropical Institute, PO Box, 4002 Basel, Switzerland, Telephone: 41–61–2848221, Fax: 41–61–284–8105, E-mail: Christian.Lengeler{at}unibas.ch. Mark Grabowsky, The Global Fund to Fight AIDS, Tuberculosis and Malaria, Chemin de Blandonnet 8, 1214 Vernier, Geneva, Switzerland, Telephone: 41–22–7915943, Fax: 41–22–7911701, E-mail: Mark.Grabowsky{at}theglobalfund.org. David McGuire, Academy for Educational Development, 1875 Connecticut Avenue, NW, Washington, DC 20009, Telephone: 202–884–8506, Fax: 202–884–8844, E-mail: dmcguire{at}aed.org. Don deSavigny, Swiss Tropical Institute, PO Box, 4002 Basel, Switzerland, Telephone: 41–61–2848160, Fax: 41–61–284 8105, E-mail: D.Desavigny{at}unibas.ch.
Reprint requests: Christian Lengeler, Swiss Tropical Institute, PO Box, 4002 Basel, Switzerland, Telephone: 41-61-2848221, Fax: 41-61-284 8105, E-mail Christian.Lengeler{at}unibas.ch.
|
REFERENCES |
|
TOPABSTRACTINTRODUCTIONITNS: WHAT VISION?ITN UPSCALING: ONLY WITHIN...DISTRIBUTION OF FREE NETS...DEVELOPING THE COMMERCIAL SECTOR...SUMMARY AND CONCLUSIONSREFERENCES |
|---|
This article has been cited by other articles:
|
|
 |
|
  J. G. Breman, M. S. Alilio, and N. J. White Defining and Defeating the Intolerable Burden of Malaria III. Progress and Perspectives Am J Trop Med Hyg, December 1, 2007; 77(6_Suppl): vi - xi. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
