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There are some basic concepts which should be taken into consideration in planning and implementing ITMN programmes. These are for example:
The overall objectives of ITMN programmes are to ensure the prevention or reduction of mortality and morbidity.
However, the primary and immediate emphasis is on the reduction of severe malaria and deaths, prioritized to high risk groups i.e. children under 5 years, pregnant women, and other high risk groups as identified at local levels.
The programmes will provide facilitating environments, and create opportunities to ensure easy access to ITMNs to all those exposed to a high risk of contracting malaria.
ITMN implementation as a public health (malaria prevention and control) intervention follows three basic patterns:
· As a method of personal protection for high risk groups;· As a method of transmission control with a target of high coverage exceeding 80% of the entire population in an operational area;
· General promotion of ITMN use as a method of personal and family protection by communities in endemic areas, and focused on information, education and communication (IEC).
· Children under 5 years, and pregnant women as the first priority in all situations;· Non-immunes and refugees moved to areas with stable or intense malaria transmission;
· All those living in areas of unstable malaria;
· Populations living in areas where resistance to antimalarial drugs seriously interferes with treatment of clinical cases
· Populations/work forces such as in development projects (agriculture, irrigation, industrial), regimented/armed forces who may receive ITMN services through their employers for malaria prevention; these however will not be target groups for health authorities
· Older children and adults who can be more easily accessed through schools, hospitals/health clinics etc. where the organization provides better opportunities for distribution;
ITMN implementation is relevant where its efficacy has been ascertained or is anticipated. The efficacy predisposing factors or determinants related to the vectors, the insecticides used for net treatments, and the potential net users must be clarified or known. The behaviourial characteristics of the vector involved, i.e. feeding habits (indoors/outdoor feeding preferences, peak biting periods) in relation to the people's sleeping patterns (indoors or outdoors); the preferences for feeding on humans or animals; the night time movements of people (varying according to age, gender, occupation), and seasonal variations in net use patterns could influence the efficacy of an ITMN strategy.
ITMNs are expected to be more effective when the target vectors are anthropophilic (primarily human biting), endophagic (feeding indoors) and when peak feeding times occur when people are under the protection of the ITMNs. The efficacy will be less when the vectors feed and rest outdoors, and when people are outdoors (not under the protection of ITMNs) when vector mosquitoes are biting.
A number of socio-cultural aspects influence community compliance and the prospects and opportunities for ITMN implementation, either positively or negatively.
ITMN implementation may be favoured where:
· people already use mosquito nets or are accustomed to do so,· people are sensitive to nuisance insects/mosquito disturbances, recognize the benefits of mosquito net-use and can therefore be motivated to use them,
· people incur heavy expenses on household mosquito control, may not be aware of the relative benefits of ITMNs use (compared to most other anti-mosquito measures) and the relative costs and benefits of ITMNs are convincing and can be demonstrated,
· people have experienced house spraying programmes, insecticide uses and their benefits,
· people are willing to have the mosquito nets already owned by them treated with insecticides,
· other vector borne diseases are also major public health problems and against which the use of ITMNs are proven or known to provide cross-benefits.
ITMNs delivery may be difficult and their usefulness questionable when people sleep outdoors due to hot humid weather or to protect their harvest from theft or wild animals (unless they can be motivated to use suitable nets under such circumstances/outdoors), or if they stay outdoors most of the night such as during religious or other festivals.
ITMN service delivery may be more realistic and promising where potential delivery systems already exist or can be accessed within the operational areas. These may be:
· Properly functioning district health management systems including primary health care (PHC) systems;· Other formal and non-formal, structured networks/systems which may exist within and outside the health sector and which may reach or are accessible to the communities. These may be already involved in ITMN related activities or may have the potential to do so;
· Well structured, operationally functional NGOs, local associations which are already engaged in ITMN activities or may be motivated to do so, given the necessary inputs;
· When people have confidence in the community leaders;
· When women play lead roles in health care in the community, or can make decisions in the household, and when the potential exists for women's associations to be involved in ITMN activities such as sewing/selling of nets;
· When private sector/marketing services reach the peripheral communities.
The availability of, or the potential to access, such services are important for immediate and long-term planning.
Economic feasibility and affordability relates to the ITMN users, providers and the programme implementers.
The economic status of the target populations varies among and within communities, the rural and the urban, those in the private and public sectors, and others such as work forces in development projects. This affects net ownership, and the ability to pay for insecticides and net (re)treatments. It is necessary to ensure that those at highest risk and who cannot afford also have access to ITMNs. Prospects of providing all or some of the services free or subsidized, at least initially, may be examined for this purpose.
Economic feasibility at the programme or provider level should be viewed as a long-term commitment. Programmes started in haste with no long-term prospects in view are not sustainable. This may happen with donation of nets with no plans for insecticide-(re)treatments, or net-replenishment. Programmes with communities paying for the nets, ideally also for the insecticide treatments, with the financial management of procurements/sales being handled through community-based cost-recovery systems/revolving funds, are likely to be more sustainable. Initial investments/external inputs could contribute favourably to start the programme through guidance and support to establish and manage cost-recovery systems. Support may be provided for capacity building/training, with seed money, logistics and technical inputs. Sustainability issues must be clarified from the beginning to avoid breakdown of programmes initiated with external funding and free supplies.
ITMN programmes are integral parts of National Malaria Control Programmes (NMCP). Their implementation however involves a range of actors within and outside health services including communities, the private sector and the donor community. Suitable arrangements are needed to link these with NMCPs, for effective partnerships at each level of implementation, and to manage the overall implementation.
Resources, service delivery, and impact on malaria are main concerns; to sustain these it is necessary to:
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· Make proper arrangements for effectively functioning logistic services, management, and coordination with other agencies, including bulk procurements; · Establish and incorporate ITMN-based information bases/systems into those of national malaria control programmes, and develop close links with the information systems of other relevant sectors and bodies; · Ensure continued availability of nets and insecticides at community/user levels to prevent loss of community confidence and interest in the programme. This may be linked with sustained low prices of nets and insecticides, and suitable management systems for the cost-recovery to ensure renewal of stocks and finances; · Ascertain efficacy of insecticides and ITMNs on the target vectors and additional benefits on nuisance pests; · Demonstrate and disseminate information periodically on the efficacy and cost/effectiveness of ITMNs to the providers and users; · Find ways to maintain motivation and sustained commitment of all partners, for instance by making adequate provisions for recognition of contributions, especially of NGOs and national partners whose normal renumerations and benefits do not match those in the private sector/external partners; · Consider incorporating (as relevant) nets, insecticides for net treatments, and ITMNs in the essential drug programmes, sick child programme, home package, and other sustainable delivery services which provide opportunities and access to specific target groups; · Ensure institutional and collaborative arrangements for malaria control which also incorporates ITMNs, to support the management, effective partnerships, community, intersectoral and multidisciplinary actions, decentralization, and policy issues; · Clarify responsibilities, including those of the promoters and the community. |
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