Guidelines on the Use of Insecticide - Treated Mosquito Nets for the Prevention and Control of Malaria in Africa (WHO - MAL - WHO - AFRO - WHO, 1997, 88 p.) 10. Annexes Annex 1. Events contributing to end use of ITMNs Annex 2. Examples of estimating required number of mosquito nets: (net targeting focused on special risk groups) Annex 3. Examples of estimating required number of mosquito nets: (targeted for an entire population at risk) Annex 4. Information to guide ITMN implementation Annex 5. Potential sources of information for ITMN programmes Annex 6. Roles/responsibilities of potential partners Annex 7. Framework for collaborative/partnership planning Annex 8. Examples of monitoring process targets and monitoring indicators Annex 9. Examples of operational research priorities

Guidelines on the Use of Insecticide - Treated Mosquito Nets for the Prevention and Control of Malaria in Africa (WHO - MAL - WHO - AFRO - WHO, 1997, 88 p.)

10. Annexes

Annex 1. Events contributing to end use of ITMNs

NCMC = National Coordinating Committee for Malaria Control
MC = Malaria Control Programme
n = national level	c = central level	d = district level
p = peripheral level	com = community level

Activities	By whom & (at what level)	How/mechanism	Conditions/Support needs
Political commitment
Establish policy framework	Ministry of health, macro-economic level policy/decision makers (n)	Collaboration/participation of NCMC	Relevant technical and policy implied information
Institutional set up and characteristics
Establish institutional, collaborative framework	Policy, decision makers, health services, NCMC (n, c, d, p, com)	Macro-level in collaboration with NCMC; clarify roles	Motivated partners, collaborators; clear responsibilities
Incorporate MC/ITMNs in health systems reform structures	Ministry of Health, NCMC, MC (n, c)	Macro-level decisions, in consultation with NCMC	Health systems reforms planned/ongoing
Define & delegate responsibilities	NCMC, MC (n, c, d)	Participatory, decisions led by MC	Clear idea of needs from each actor
Establish framework to motivate workforce	NCMC (n, c)	Develop formal/informal processes	Managerial commitments
Establish procurement systems	Macro-economic level, NCMC (n, c)	Interact with import regulatory bodies	Commitment/motivation macro-level decisions
Planning
Establish target priorities	NCMC, MC (c, d)	Stratification, analysis of information/data	Reliable information & efficient information management system
Prepare plans of action	NCMC, MC programme planners (c, d)	In consultation with district level, other relevant partners	Clarified objectives, resource status
Make needs assessments	NCMC, MC programme planners (n, c, d, p, com)	In consultation with district level, other relevant partners; compare with available and needs according to plan, assess targets	Information on available, additional needs
Information, education and communication
Establish/maintain efficient information management system	NCMC, MC (n, c, d, p)	Plan, exchange/use information, computerization	Trained, motivated personnel; processes for information flow
Convince policy/decision makers, financing bodies (DSAs, and ESAs)	Malaria control programme managers/scientists, NCMC (c)	Demonstrate/highlight disease problem, potential role of ITMNs and promotional needs	Convincing data, information, and presentation
Create motivated workforce	NCMC, MC, all partners (c, d, p, com)	Recognize/appreciate contributions Give special remunerations	Processes/mechanisms to recognize exceptional contributions
Mobilize community	All partners (c, d, p, com)	KAP surveys, IEC, training, skills	Knowledge on communities' needs, attitudes, perceptions, practices, interest, resources
Use insecticide-treated nets properly	Individuals, households, communities (com)	IEC on potential, & conditions for use	Community awareness, knowledge, interest, access, affordability
Technical information and choices
Assess needs-resources, training and research	NCMC, MC (n, d, com)	Situation analysis, collaboration	Proper planning, & information
Provide information on insecticides, nets, sources, specifications, costs, safety aspects to the providers & implementers	MC personnel (c, d, p)	Interaction with WHO, industry, dissemination of information, documentation guidelines, newsletters	Efficient information management systems, regular access to new information
Choose insecticide(s), formulations, dosages	Scientists of NCMC, MC (n, c)	Local experiences Seek guidance Use information system	Access to information knowledge, guidance, insecticide registration, vector susceptibility
Select treatment method: dipping or spraying	District level implementers (d, p, com)	Estimate number of nets to be treated & decide	Knowledge on local needs and on methods
Select monitoring indicators	Scientists in MC, academic/research institutes	Decisions according to target objectives	Clear objectives, guidance
Establish treatment processes, undertake (re)treatments on schedule	Relevant scientists, field implementers (d, p, com)	Prepare (re)treatment schedules, mobile systems	Treatment sites, access to insecticides/basic supplies on time, trained/skilled personnel, and delivery services
Training
Provide guidance	Competent technical personnel (c, d, p)	Use guidelines, training material	Availability of guidelines, training material, knowledge, skills
Train for treatments	Trainers, implementers (c, d, com)	Select trainers, trainees, implementers and train	Knowledge skills, facilities
Funding
Mobilize funds	a) Central level, NCMC (n, c) b) Malaria control programme managers & NCMC (c, d)	a) Convince financing bodies, seek support b) Needs assessment, convince policy & decision makers, interact with potential donors, & partners	National level commitment to malaria control and financing, donor interests, and commitment, sound plans of action
Procurement, local manufacture
Make timely and effective bulk procurements	NCMC, MC managers, NGOs, donors (c, d, com)	Coordinate country's needs for a specified period, use of national, regional or sub-regional procurement systems (to be established)	Efficient procurement system(s), import tax/duty exemptions, knowledge on specifications, sources, costs
Purchase/sell at costs, subsidized prices	Net-users, immediate providers (c, d, com)	Suitable distributory channels, subsidized costs Cost recovery systems	Information on sources/distribution systems, low costs, affordability, access/availability, storage, distribution channels at all levels
Obtain/procure material, promote local sewing of nets	All promoters, supporters, implementers, NGOs (c, d, com)	Encourage NGOs community, community-based and cost-recovery systems, private sector; provide information on specifications, facilitate access to sewing machines	Community, private sector, NGO interest Access to netting/material, sewing machines Information on designs, measurements, sizes, mesh, denier, loans to buy, subsidized costs, donations, seed money
Promote/encourage, commercial manufacture of nets in the country	Decision/policy makers, NCMC	Remove/reduce tax, regulatory measures, provide subsidies, loans to business/consumer	Commitments, recognition of the need, guidance, monitoring, supervision
Storage and delivery, marketing
Store nets and material properly	Implementers (n, c, d, p, c)	Seek storage facilities within & outside health sector	Easily accessible storage near or within target areas
Retail nets, netting/material	Implementers (n, c, d, p, com)	Identify/access to distributory mechanisms within and outside health including private sector	Infrastructures, distribution processes Access to transport, other delivery systems
Distribute to stores & user levels/treatment sites	District level management (c, d)	Seek help of other delivery systems	Access to transport, delivery mechanisms/schedules Storage sites near/within target areas
Ensure insecticide (re)treatments on schedule	Providers, implementers, individuals, households, communities (d, p, com)	Establish treatment sites, mobile arrangements, seek treatments	Planning, insecticide availability on time, (re)treatment mechanisms, access to (re)treatments sites, skills knowledge, awareness
Financing: subsidies, grants, cost recovery
Sale at cost, or at subsidized prices	Managers of MC, community organizations (d, p, c)	Cost-recovery systems, through suitable government channels, NGOs, community organizations, private commercial sector/shops	Price control, cost-recovery systems, financial management processes, monitoring and supervision
Provide free (exceptionally)	MC/health services, managers of ITMN programmes (d, p)	Prioritize targets, prioritize/identify those at highest risk, deserving free	Information on most deserving i.e high risk/cannot afford; resources/funds
Provide seed money, financial, and managerial support to community-based net delivery systems	Planners, managers (c, d, p)	Cost recovery systems, subsidized supplies, donor inputs	Availability of seed money, donor support
Meet costs of (re)treatments: free, subsidized, or at full cost	Net users, managers, implementers (c, d, com)	Support from public funds, cost-recovery systems	Financial commitment and management/cost recovery mechanisms, affordability
Monitoring, evaluation, quality control
Ensure adherence to policies, standards	Planners, managers, supervisors of malaria control & ITMN implementers (n, c, d)	Disseminate relevant information, provide guidance, monitor including procurements, supervise, undertake quality control	Guidelines, information, knowledge, competence and resources/facilities for quality control
Ensure proper mixing, dosage, treatment, drying of treated nets	Managers, implementers (c, d, com)	Training, monitoring, supervision, quality control	Guidelines, knowledge, information, skills
Quality assurance of pyrethroids used	Scientists of control programmes, academic, research institutes (n, c, d)	Special studies, collaborate with academic, research institutes, networking programme	Access to quality control facilities, external/WHO support
Ensure continued efficacy (including vector amenability) to pyrethroids in use Make quality assurance of pyrethroids used & treatment efficacy Undertake resistance monitoring	MC, academic, research institute scientists (n, c, d)	Vector resistance monitoring, field investigations, Bioassays & chemical analysis on samples of treated nets Collaborate with research/academic institutes	Skills, training, supplies, access to field material Access to quality control facilities Special studies, external (WHO) support
Ensure net washing preferences, i.e. to wash before (re)treatments, avoid/minimize after treatments, when washed often to get retreatments	Providers, supporters, implementers of ITMNs (d, p, com)	IEC on requirements, provide treatments opportunities	Communication opportunities, access to treatment facilities, resources for lECs
Ensure proper use of treated-nets	Providers, implementers (d, p, com)	IEC including on conditions for proper use, benefits etc.	Communication opportunities, resources
Monitor operational process, target indicators	MC and ITMN programme managers and implementers (c, d, p)	Based on sound plan with clear indicators, formats, guidelines, etc.	Monitoring plan, resources, defined indicators and processes
Assess impact on disease	MC and ITMN programme managers and implementers, and researchers (n, c, d)	Use of surveillance data, sample surveys, specific plans developed	Efficient information management & surveillance systems, good recording, reporting
Operational research
Identify operational research needs	MC and ITMN programme managers and implementers, and researchers (n, c, d, p, com)	Consultation among MC and ITMN programme managers and implementers and researchers	Knowledge/exposure, field operations, experiences, issues of concern including non-response to intervention
Carry out problem-solving research	MC personnel, research/academic institutes (n, c, d)	In collaboration with malaria control, field implementers	Resources, skills technical inputs/guidance
Support operational research	Planners, supporters/funding agencies (n, c)	Provide resources/funds, guidance, technical inputs	Competence, resources, guidance
Guidelines to country-specific needs
Develop country-specific handbook based on AFR guidelines	MC staff in collaboration with other partners (c, d, p, com)	Adapt accommodated to national/local needs	Exposure to field, real life issues and needs

Annex 2. Examples of estimating required number of mosquito nets: (net targeting focused on special risk groups)

Year	1	2	3	4	5
Total population	12,000,000	12,360,000	12,730,800	13,112,724	13,506,106
Proportion living in stable malaria transmission areas	66.70%	66.70%	66.70%	66.70%	66.70%
Proportion aged 0-4 years	18.40%	18.40%	18.40%	18.40%	18.40%
Proportion aged 15-44 years	41.30%	41.30%	41.30%	41.30%	41.30%
Population living in stable malaria transmission areas	8,004,000	8,244,120	8,491,444	8,746,187	9,008,573
Number of children aged 0-4 years living in stable malaria transmission areas	1,472,736	1,516,918	1,562,426	1,609,298	1,657,577
Number of people aged 15-44 years living in stable malaria transmission areas	3,305,652	3,404,822	3,506,966	3,612,175	3,720,540
Number of females in age group 15-44, assuming a sex ratio of 1:1	1,652,826	1,702,411	1,753,483	1,806,088	1,860,270
Proportion of pregnant women aged 15-44 living in stable malaria transmission areas	25.00%	25.00%	25.00%	25.00%	25.00%
Number of pregnant women in a stable malaria transmission areas (SMTA)	413,207	425,603	438,371	451,522	465,068
Target protection coverage for children 0-4 years	50.00%	50.00%	50.00%	50.00%	50.00%
Number of children 0-4 years covered by the program	736,368	758,459	781,213	804,649	828,789
Number bednets for children age 0-4 years assuming that 2 children sleep under 1 bed net	368,184	379,230	390,606	402,325	414,394
Target protection coverage for pregnant women	50.00%	50.00%	50.00%	50.00%	50.00%
Number of pregnant women under the impregnated bed nets intervention living in SMTA	206,603	212,801	219,185	225,761	232,534
Number of pregnant women provided bet nets in previous years	-	41,321	75,617	104,331	128,617
Number of new bed nets required for pregnant women each year	206,603	171,481	143,569	121,430	103,917
Number of children aged 0-4 provided bed net in the previous year	-	276,138	284,422	292,955	301,743
Number of new bed nets for children aged 0-4 years each year	368,184	103,092	106,184	109,370	112,651
Total number of bednets required for children 0-4 and pregnant women (at 50% coverage)	574,787	274,572	249,753	230,800	216,568

Annex 3. Examples of estimating required number of mosquito nets: (targeted for an entire population at risk)

Year	1	2	3	4	5
Total population	12 000 000	12 360 000	12 730 800	13 112 724	13 506 106
Proportion (%) living in stable transmission areas	66.7	66.7	66.7	66.7	66.7
Proportion (%) living in unstable transmission areas	20.00	20.00	20.00	20.00	20.00
Population living in stable transmission areas	8 004 000	8 244 120	8 491 444	8 746 187	9 008 573
Population living in unstable transmission areas	2 400 000	2 472 000	2 546 160	2 622 545	2 701 221
Total population to be protected	10 404 000	10 716 120	11 037 604	11 368 722	11 709 794
Number of nets required to protect entire population	5 202 000	5 358 060	5 518 802	5 684 361	5 854 897
Number of nets required to protect 50% of population	2 601 000	2 679 030	2 759 401	2 842 180	2 927 448

Annex 4. Information to guide ITMN implementation

A. Types of General Information

1. Country background e.g. major socio-economic, demographic, and climatological.

2. National policy on ITMNs, and existing institutional and collaborative arrangements for malaria control, and (if any) for ITMN activities.

3. Major areas/situations in the country likely to be priorities for ITMN implementation, i.e. areas with high malaria-related mortality and morbidity, and severe malaria, drug resistance problem, and high and seasonal transmission, and with other special risk groups such as mobile populations, refugees moved to highly endemic areas.

4. National structures/authorities responsible for, or could facilitate or influence:

¨ Establishment of policy, institutional and collaborative framework for health services and malaria control;

¨ Exemption of taxation/duty on imported materials;

¨ Creation of opportunities for local production of material including removal/reduction of regulatory measures which may deter local manufacture;

¨ Registration, and decisions on insecticide imports in particular for public health and IIMNs;

¨ Establishment of procurement systems;

¨ Interaction/co-ordination with support agencies (domestic and external) of national malaria control and ITMN programmes;

5. Types of ongoing health sector reform structures/processes which can accommodate ITMN related issues.

6. National Institutes of Public Health, academic and research institutes, and scientists involved in ITMN related work, or with such potential.

7. Existing formal and informal structures within and outside the health services (both public and private), and community-based ones involved in, or have the potential to participate in ITMN services.

8. Types, status, magnitude of ongoing ITMN activities (organised or ad hoc) in the country.

9. Types of experiences (positive & negative), of other community based programmes, on community mobilisation, inter-sectoral activities, in the involvement of volunteers so that they may be used as examples for extrapolation, or may be avoided in ITMN programmes.

B. Types of ITMN target/delivery specific information

1. Transmission intensity and seasonality.

2. Disease status/incidence: Estimates on mortality/morbidity (or parasitological if available) especially in relation to children and pregnant women.

3. Estimated populations

¨ In the general (major) administrative areas within which ITMN activities are envisaged;

¨ In the specified areas where ITMN operationalization is ongoing/planned;

¨ Involved in each type of high/special risk population groups, i.e. children under 5 years;

¨ Pregnant women, displaced persons/refugees;

¨ In different types of high or special risk areas, e.g. with drug resistance problem.

4. Entomological/vector related information: The main vectors and their host feeding preferences, biting locations (inside, outside houses), the periods of maximum feeding, and recent information on vector susceptibility status to insecticides in use and to be used for net-treatment.

5. Nets/material, insecticides, insecticide-(re)treatment:

Nets:

¨ types, material, designs, mesh sizes, etc. of nets which are most suitable and are available or accessible, their sources and costs;

¨ types (material, sizes, shapes) commonly used by target communities.

Sewing nets: suitable measurements, designs.

Insecticides: recommended/suitable, the types, formulations, dosages; sources/costs.

(Re)treatment of nets:

¨ Opportunities/facilities for net-treatment (locations of treatments, demonstration sites, mobile arrangements), timing/schedules, treatment frequencies according to insecticides/formulations.

¨ Net treatment procedures and costs.

6. Existing “formal” structures/networks

Within health (e.g. PHC, MCH/antenatal, EPI, sick child), and outside health (e.g. education, communications/media, water, irrigation, agriculture) and which of these (a) are already involved in ITMN activities, the type of activities and processes, and those efficient and have grass root linkages, and (b) have potential to participate in ITMN activities.

7. Existing “less formal or informal” structures/networks/bodies

Schools, village committees, women's and religious/church groups, NGOs already involved in ITMN activities; their membership, types of activities and processes. Which of these have good, efficient grass root linkages, political strengths; or have potential to do so.

8. Ministries, extension services which work effectively with communities.

9. Knowledge/experiences on women's:

a) status, and social and economic participation in any development activities in the community,

b) influence in the household with decision making implications on net ownership and use at household, payments for nets, insecticide treatment,

c) influence in community-based activities including ITMNs.

10. Socio-cultural, and economic aspects (documented, known or experiences, and through KAP surveys) on:

¨ Estimates on proportion of people using nets;

¨ Type of nets (designs, sizes, materials, colours), preferences and in use;

¨ Net washing habits.

¨ Community perceptions related to malaria, mosquitos, use of mosquito nets and curtains, and on their associations with each other;

¨ Social and economic issues likely to influence ITMN programme including the choice, and use of nets, and affordability of the communities concerned and their perceived benefits of bednets; attitudes, beliefs concerning net use;

¨ Educational and literacy status including of women;

¨ Types of occupations in households at highest malaria risk, their ability to buy nets and pay for insecticide-treatment;

¨ General sleeping habits and movements at night of people of different age groups in relation to, and influencing net use patterns;

¨ People's sensitivity to nuisance from mosquitos, bedbugs, fleas, lice, etc.;

¨ Types of anti-mosquito methods (nets, coils, other repellents) in use, and costs incurred.

Annex 5. Potential sources of information for ITMN programmes

¨ Health services/malaria control programmes;

¨ Non-health sectors (e.g. education, communication/media, agriculture, water and sanitation, industry, and other private sectors;

¨ Tropical diseases, epidemiological or preventive departments;

¨ Research and academic institutes;

¨ Schools, local leaders, households, NGOs, community organizations (women's groups, church/religious groups, village community groups/workers), private sector/companies, other social structures;

¨ International organizations (e.g. WHO);

¨ Development banks;

¨ Findings from special studies/research;

¨ Publications, documents/reports;

¨ Networking programmes (proposed), WHO collaborating centres.

Annex 6. Roles/responsibilities of potential partners

1. National/Central Level

Political commitment.

Establishment of policy frameworks.

Establishment/adjustment of institutional and collaborative frameworks.

Establishment of procurement systems, import duty/tax exemptions for nets, material, and insecticides.

Creation of opportunities to motivate local tailoring of nets.

Participation in the National Coordinating Committee for malaria.

2. Health services/malaria control programme (central level)

Information management systems

¨ Maintain an updated national level information management system.

¨ Maintain global information covering specifications/standards, sources of nets, material, insecticides, equipment, costs, technologies, processes.

¨ Stimulate documentation, dissemination and sharing of ITMN implementation related experiences within and outside the country including WHO.

Standards/guidelines

¨ Establish and ensure adherence to policies, legislations, standards and procedures related to insecticides, nets and insecticide treatment of nets.

¨ Develop, adapt/elaborate global/regional guidelines and training, educational materials to meet the country specific needs, and disseminate to potential users.

Planning

¨ Establish national procurement system for ITMNs, and interact with regional or sub-regional procurement systems (expected to be developed) for speedy procurement of quality assured materials at low costs.

¨ Undertake national/macro-level stratification, define major priority targets (areas, populations) for ITMNs.

¨ Prepare country level plans of action, assess needs to operationalize activities, mobilize and distribute resources.

¨ Make decisions and commitments on ITMN distribution/delivery systems and processes, in consultation with the collaborators.

¨ Define/assign responsibilities and tasks of malaria control services personnel, and other collaborating partners at each level of implementation.

¨ Assign health workers to participate in the insecticide-treatment of nets.

¨ Support district level macro-, micro-level stratification, planning, needs assessments, resource mobilization, and training activities.

¨ Help/organize financial management, revolving fund/cost-recovery systems.

Training

¨ Undertake training and education (mainly of trainers, and district level implementers), and where necessary in collaboration with national academic and research institutes, WHO collaborating centers/networking programmes.

¨ Establish and maintain a national ITMN demonstration centre for training, education, sensitization, and demonstrations and net treatment.

Collaboration/coordination

¨ Participate and collaborate in NCMC activities.

¨ Interact with other promoters and supporters including DSAs and ESAs of ITMN implementation.

¨ Interact, coordinate, influence, or link-up (as relevant) with those who could make commitments, or influence national level financing, policies, legislature.

* Inputs and activities to the country or operational areas through different sources within and outside the country.

* With relevant personnel of other sectors already involved in, or have the potential for ITMN delivery services, or for making decisions and commitments on distribution or delivery systems and processes.

* In KAP surveys, and development and dissemination of IEC messages.

* With district level, in monitoring and evaluations.

Monitoring and evaluation

¨ Select indicators to meet national/local needs, and target objectives.

¨ Monitor, evaluate, supervise.

* Processes, activities, delivery/distribution systems, storage, net-treatment, financial management; and achievements/progress, and impact.

* Maintenance of standards, specifications.

* Coordinating systems.

* District level implementations.

¨ Ensure implementations according to strategy, achievement of objectives and targets, and that the guidelines are followed, and the policies and legislations are adhered to.

¨ Feedback, suggest or guide adjustments, improvements.

¨ Establish, undertake a programme for monitoring vector resistance to pyrethroids, investigate practical implications of resistances in field operational, if necessary in collaboration with other national research/academic institutes, and WHO collaborating centres/networking programme.

Operational research

In collaboration with relevant district level personnel, and academic/research institutes identify, prioritize, promote, support or undertake operational research of immediate relevance to ITMN implementations

3. District level

Many national level activities are also applicable to the district level though some of them only to a limited degree. The primary responsibilities may be:

Planning

¨ Undertake district level macro- and micro-level stratification, target prioritisation, needs assessment including for community-based activities, and prepare district level plans of action.

¨ Mobilise resources if relevant in consultation with the central level.

Information management: collection, use/exchange

¨ Maintain updated district/peripheral level information relevant to guiding, planning, implementation and evaluation.

¨ Collect information on operations, processes, experiences, attitudes/perceptions of communities on implementations, develop and disseminate appropriate IEC messages.

¨ Exchange information with the central, peripheral/community levels.

¨ Feedback for concurrence and advise from the central level, and for remedial actions at peripheral levels.

¨ Make appropriate programme adjustments.

Co-ordination/partnership

¨ Identify and collaborate with district level partners in planning, and resource mobilisation.

¨ Define responsibilities of collaborating partners in consultation with central level management, and with the collaborators.

¨ Interact with health/non-health public sectors, private sector, NGOs to access their networks of delivery services for ITMN delivery, and for collaborative activities.

Training, guidance and education

¨ Adapt national guidelines to district/local-specific needs.

¨ Train district, peripheral level health personnel, and other ITMN collaborators including communities.

¨ Undertake/promote community education and sensitisation activities:

¨ Establish district level ITMN demonstration center(s) for insecticide treatment, training and community sensitisation activities.

Logistics, financing, delivery services

¨ Co-ordinate supply management, storage, distributions.

¨Identify and establish distribution structures, mechanisms, processes (in consultation with central level management).

¨ Prepare and adhere to distribution schedules to ensure material availability at user-levels on time.

¨ Help/guide establishment and management of financing processes (e.g. revolving funds) at the periphery and community levels.

Supervision, monitoring

¨ Supervise district, peripheral and community level activities and processes, e.g. net and insecticide distribution, net (re) treatment, community use of nets, financial management.

¨ Participate in monitoring vector resistance to insecticides, quality assurance of insecticides and their applications; (in collaboration with central level, and academic/research institutes).

¨ Monitor adherence to standards and specifications.

Reporting

¨ Report to national/central level relevant findings (especially of any significance) and achievements/progress, shortcomings.

4. Peripheral/community level

Planning

¨ Participate in the planning/replanning of community activities, if needed with district level inputs.

Information, training, education, sensitisation

¨ Share information with community members and the district level.

¨ Collate information on community perceptions, beliefs, practices, compliance coverage (use, washing, re-treatment).

¨ Contribute to, or participate in the district level development of IEC messages, and in their dissemination including education, and community sensitisation.

Logistics, financing

¨ Ensure/manage logistics at this level.

¨ Establish and manage suitable funding mechanisms, cost-recovery systems for nets, and net-treatment.

Training

¨ Co-ordinate, facilitate or undertake training at local/community levels.

¨Establish local demonstration center for insecticide treatment and training.

Coordination

¨ Co-ordinate and facilitate net distribution, and insecticide (re)treatment.

¨ Interact and collaborate with local level NGOs, community associations, schools, churches/religious centres, commercial outlets, health and non-health networks operating in the areas, on ITMN related activities.

¨ Participate in or undertake monitoring of community level activities.

¨ Feedback to district levels and the community for necessary adjustments.

¨ Promote or organize net sewing by community members/groups.

5. Non-governmental organizations (NGOs)

The responsibilities/contributions vary at different levels depending on the respective strengths. Overall they may:

¨ Participate in respective collaborative committees depending on level of location.

¨ Collaborate with the national level concerning procurements, imports, storage, distribution of nets/insecticides.

¨ Provide financial/logistic support, and help manage community-based actions.

¨ Assist or participate with the health authorities and other public and private sectors/agencies in relevant activities, mainly on service delivery.

¨ Participate in education, and sensitisation of communities.

¨ Contribute to information bases depending on their sources of information, and what they collect.

6. Local community groups

¨ Co-ordinate or undertake storage, and distribution of nets, insecticides, and insecticide-treatment of nets.

¨ Co-ordinate and promote sewing of nets at community level, when applicable.

¨ Undertake financial management e.g. cost-recovery systems/revolving funds.

¨ Monitor community compliance, e.g. net washing practices, use of nets.

¨ Examine community perceptions, beliefs, practices on net, insecticide uses, etc., and influence community towards proper use of treated-nets.

¨ Participate/undertake community educational/sensitisation activities.

¨ Exchange information with the NGOs ate local and district level, and with the community members.

7. Private sector/industry

¨ Contribute to service delivery through own networks of delivery services especially in the reach of populations in remote areas.

¨ Provide relevant co-ordinating committees with information on nets/material, insecticides, their sources, specifications and costs.

¨ Undertake local sewing of nets, production of material for ITMNs at prices and of quality which compete with the imported.

¨ Contribute with financial, logistic support.

8. Individuals/Households at malaria risk (the net-users)

¨ Procure nets.

¨ Pay for insecticide treatment of nets.

¨ Get nets (re)treated on schedule, but wash nets before treatment, avoid frequent washing of treated nets, when washed often get them re-treated.

¨ Ensure proper use of treated nets in the house.

9. Research and academic institutes and scientists

In collaboration with the central and district level malaria and ITMN implementers:

¨ Participate/undertake training, operational research, insecticide resistance monitoring, KAP surveys; checks on bio-efficacy insecticide treated nets, and quality of the insecticide applications.

¨ Contribute to the information systems providing relevant technical information such as on vector behaviour, insecticide susceptibility status.

10. Other Domestic Support Agencies (DSAs), and External Support Agencies (ESAs)

¨ Provide financial, and logistic support.
¨ Participate in relevant activities, e.g. training, development of training and educational materials.
¨ Contribute to development of information systems.

11. Regional, sub-regional networking programmes

¨ Support and co-ordinate:

* Speedy, low cost, quality assured bulk procurement.
* Monitoring of vector resistance, to some extent of nuisance insects.
* Information sharing including on operational and research experiences.
* Training.

Annex 7. Framework for collaborative/partnership planning

PARTNERS/PARTNER INSTITUTES
Activity/Task	Macrolevel decision makers	Health/malaria control staff	Other government sectors	Academic/research institutes	NGOs	Community groups	Private sector	Other support agencies
Political commitment, Institutional set up and characteristics
Establish policy framework
Establish institutional, collaborative framework
Incorporate MC/ITMNs in health systems reform structures
Define & delegate responsibilities
Establish framework to motivate workforce
Establish procurement systems
Planning
Establish target priorities
Prepare plans of action
Make needs assessments
Information, education and communication
Establish/maintain efficient information management system
Convince policy/decision makers, support agencies
Create motivated workforce
Mobilize community
Promote proper use of ITMNs
Technical information and choices
Assess resources, training and research needs
Provide information on materials (sources, specifications, costs, safety) to providers, implementers
Choose insecticide(s), formulations, dosages
Select treatment method(s)
Select monitoring indicators
Establish treatment processes, undertake (re)treatments
Training
Provide training and guidance
Funding
Mobilize funds
Procurement, local manufacture
Make procurements on time
Purchase/sell nets at cost, subsidized
Promote local sewing of nets
Promote local commercial manufacture of nets
Storage and delivery, marketing
Store nets and material properly
Distribute to stores, user levels/treatment sites
Ensure insecticide (re)treatments on schedule
Financing: subsidies, grants, cost recovery
Sale at cost, or subsidized
Provide free (exceptionally)
Provide seed money, other support to community based net delivery systems
Meet costs of (re)treatments free, subsidized, or full cost
Monitoring, evaluation, quality control
Ensure adherence to policies, standards
Ensure proper mixing, dosages, treatment procedures
Ensure quality assurance, treatment efficacy, efficacy on vectors of pyrethroids used,
Undertake vector resistance monitoring
Ensure adherence to net washing requirements, i.e before (re)treatments, not soon after treatments
Ensure proper use of treated-nets
Monitor operational process, activities, target achievements
Assess impact on disease
Operational research
Identify operational research needs
Carry out problem-solving research
Support operational research
Guidelines to country-specific needs
Develop country-specific handbook based on AFR guidelines

Annex 8. Examples of monitoring process targets and monitoring indicators

Process targets	Monitoring indicators	Problem definition
200 000 nets of sizes ..., delivered at each of the 10 districts in Region A before day.... month .... year....	Number of districts out of 10 that received 200 000 nets as scheduled	Not enough nets Problems of delivery, transport, and personnel
5 million nylon nets of size ...., mesh .... to be imported to country before December 1996	Date of ordering nets Date of net delivery, or expected at port of entry	Orders made too late Late manufacture, shipment, arrivals Delays in clearance
In district A, 5 insecticide treatment centres will be established in 1996 to serve 25 groups of villages (communities) at high malaria risk	Number of treatment centres established in district A in 1996 Number of villages at high risk with access to treatment centres Of the implementing partners (health, other governmental, social, and NGOs, the proportion received information, training, required skills	Time inadequate to establish all 5 Inadequate trained personnel, supply shortage
Before peak transmission period in 1996, at least 70% of children < 5 years in all 5 communities in ........ will receive treated nets through PHC services	Estimated number of children < 5 in the 5 communities Number of PHC personnel Number of children received treated nets	Not enough nets Treatments delayed or facilities not enough Inadequate distribution services
In area A, to increase use of treated nets by children < 5 years in at least .... % of the households by January 1997, compared to January 1996	Total number households Number households where children < 5 years already use treated nets Number households with children < 5 years, given treated nets Number of households where children < 5 years sleep under nets provided Number of nets treated within 6 months of transmission period Types of IEC messages; how many households were accessed for IEC	Shortage of nets; inadequate treatment facilities; children not given priority; lack, inadequate promotional activities including IEC
In district B, one net treatment centre will be established to serve each group of 5 villages by December 1996	Number of villages in district Number with and without access to a treatment centre	No resources No or poor planning
By ...., to increase to ..... % the proportion of households using at least one ITMN	Of the households targeted the proportion with a net per bed and in use Proportion of targeted households with at least one member aware of ITMNs, their proper use and maintenance

Annex 9. Examples of operational research priorities

¨ Insecticide resistance status of malaria vectors to the insecticides in use, and potential alternatives.

¨ Vector behaviour and response to individual, household, community or village level use of ITMNs.

¨ Interaction of different types of fabrics with different insecticides (active ingredients and solvents); their effect on target vectors, and persistence of insecticides.

¨ Simple tests to quantify insecticide persistence on treated nets.

¨ Safety of insecticides (active ingredients and solvents) to humans on exposure during handling, insecticide-treatment, ITMN uses.

¨ Efficacy, stability of insecticides following storage under different conditions.

¨ Establishment and review of system for delivery of nets, insecticide (re)treatments.

¨ Training, educational and IEC materials for use at central, regional/district, community level and within and outside the public/health services.

¨ Rapid assessment methods for review, KAP before and after ITMN uses.

¨ Insecticide repackaging options.

¨ Duration of efficacy of insecticide-treated surfaces on target and nuisance insects following use, washing, and exposure to smoke, dust.

¨ Impact of IEC, training, and community involvement on communities' perceptions on mosquitos and disease, and knowledge and attitudes to ITMNs in areas with and without net-use habits.

¨ Insecticidal, killing, repellent and knockdown effects of different dosages of insecticides (including sub-lethal dosages on nets, on mosquito longevity, fertility and susceptibility to infection.

¨ Review of sensitivity, specificity, relevance of indicators, and data collection methods in use under different malaria transmission conditions, and in relation to the ITMNs programme objectives.

¨ Effects of ITMNs on malaria pregnancy in primiparous women in different epidemiological conditions.

¨ Major determinants of feasibility and sustainability of ITMN programmes.

¨ Mechanisms for effective integration of ITMNs in NMCPs, and other services within and outside public health services.

¨ Relevance of low dosages of insecticides for (re)treatment to accommodate frequent net washings.