Work Group Discussions: Relevance of Conference Themes to the Programming Process

Introduction

The heart of the conference was two rounds of work groups. In round one, conference participants were divided into four groups. These groups were further divided into groups of ten to twelve persons to discuss pertinent questions related to the four conference themes: demand, access, affordability, and appropriate use (see Box 1-1). These sub-groups consolidated their work and shared the results of their discussions. In round two, the conference moved from a thematic to a programmatic focus. Four new groups were formed to discuss the four steps in the program process and how the key thematic issues apply to those steps.

Annex 7 lists the questions given to all groups to guide their discussions.

This chapter presents the results of the two rounds of work groups.
Table 1 summarizes the groups' discussion of how thematic issues are related to the ITM programming process.

Overview of Program Steps

Assessment: Information is collected and analyzed to define the existing situation and clarify the needs, including a) biological feasibility (an entomologic profile and epide-miologic information), b) cultural feasibility to determine demand, c) institutional feasibility (the roles of the public and private sectors), and d) financial sustainability.

Planning. Based on the information from the assessment, decisions are made on how the program will address the needs. The plan should include promotion, management, training, procurement, logistics, financing, and supervision and should clearly identify the partners and their roles and responsibilities.

Implementation. Implementation addresses what needs to be done, when, where, and by whom. It includes start-up considerations, building program awareness and commitment, roles and responsibilities of key institutions, and carrying out program activities. Implementation should be geared to establishing a sustainable long-term program.

Monitoring and Evaluation. Monitoring and evaluation assesses the program's effectiveness and results. It is an ongoing process and should include what kind of health and management information system is needed, how the information will be used for decision-making, and how to measure progress and impact.

Synthesis of Work Group Discussions

Assessment

Collecting reliable information on all aspects of a potential bednet program is absolutely essential.

Demand: Creating demand or building an ITM culture can be viewed from a long-term or short-term consideration of benefits. In the short-term, desire for ITMs may be based on reducing the nuisance from mosquitos, bedbugs, and lice; increasing privacy; and, in some instances, enhancing status. Long-term benefits, which may not even be considered by customers, are reduction in illness and death. Different socio-economic groups may be moti-vated by benefits. When planning a strategy for demand creation among various groups, all facets of demand must be considered.

Box 3-1: Information Needs for Assessing Demand

Individual Consumer/Community Level Nature of the malaria problem in the community. Anti-mosquito measures currently in use (nets, coils, smudge pots, spray, repellants); their positive and negative aspects, including their costs. Lifestyle information: use/nonuse of beds, sleeping patterns, features of house construction, family decision-making. People's understanding of malaria: severity, risk, seasonality. Community access to communication channels. Community demographics: size, homogeneity, presence or absence of infrastructure, opinion leaders. National/Provincial Level (Those who would be responsible for administering an ITM program) Understanding of malaria. Knowledge of ITMs and perception of their benefits. Level of commitment to malaria control as demonstrated by supportive policies, regulations, and budget allocations. Perceived political capital to be gained from supporting an ITM program. Organization of bureaucracy. Commercial Private Sector Level A master list of all potential players in this category, including manufacturers, distributors, sellers, and companies that have distribution channels that might be used for nets and insecticides. Level of involvement in ITMs of each firm or organization identified. Ways that an ITM program might benefit them, both tangibly (profit, market share for manufacturers, distributors, and sellers) and intangibly (reputation, image). Donor Level Ability to achieve potential benefits in short and long-term time frames.

Demand for ITMs must also be created in groups and entities responsible for planning and implementing programs: private businesses, local government officials, and donors, among others. To assess demand, information must be gathered at four levels, as shown in Box 3-1.

Tools and techniques to accurately and efficiently measure demand are listed below. Before any of these tools are used, planners must reach clarity about what information they want to obtain. Information-gathering methods should be kept simple.

Professional market researchers
Compilation of experience and data gleaned from professional literature, health center records, sales reports (of anti-malarial devices), etc.
Surveys
Focus groups
Anthropological investigations.

Access
Many private companies in Africa conduct sophisticated market research surveys and campaigns. It should be possible for ITM programs to collaborate with them in obtaining information on ITM accessibility. Also, since most nets are purchased from the private sec-tor, health professionals and manufacturers/ suppliers of nets should communicate or share information on bednet and insecticide accessibility and use. However, private companies may not be willing to share what they consider proprietary information.

Box 3-2: Information Needs for Assessing Access

Functioning distribution channels railroads, roads, trucks wholesalers, retailers hawkers Distribution of customers Perceived standards of distribution LocationCurban versus rural Access to ITMs within the family unit or household These factors may not be equally relevant to nets and insecticides.

Box 3-3: Information Needs for Assessing Affordability

Affordability and Health Goals Can families afford enough nets to assure that all persons at risk have a net? If only one net can be afforded, who will use it? Subsidies Will ITMs be subsidized? Who will subsidize? Are there current subsidy patterns that exist in country? Are people used to paying for health products? (Are ITMs "health products"?) General Affordability How low must the price be for general affordability? No matter how low the price is, it will still be unaffordable for some. Research techniques are needed to investigate willingness to pay. How will the need for repeated payments for re-impregnation and replacement of worn nets affect affordability? Availability of Credit Will credit be available? Will payment schedules recognize seasonal variations in the availability of money (money is tight for some people during different seasons of the year)? Effect on Purchase of Other Anti-Mosquito Devices To what extent will use of ITMs eliminate the need to purchase other anti-mosquito devices? (There is still a problem of mosquitoes biting before bedtime.) Purchase Intent Priority What priority is given to purchase of ITMs versus other household priority expenditures?

Information should be collected on all the factors that influence household access to nets and insecticides, as shown in Box 3-2. Several market research tools have been used to assess the accessibility of bednets and insecticides:

Surveys:
mail surveys of NGOs (for a relatively low cost)
school surveys to obtain information on coverage and use of nets in households
bus station surveys
exit interviews at pharmacies
Observation techniques
Focus groups
Key informant interviews
Community profiles/mapping.

Groups to be targeted include the following:

Village medical centers
Householders
Shops
Health workers.

Affordability
There is no country in Africa where mosquito nets are not available. To assess the affordability of nets, information must be gathered on characteristics of buyers of nets: economic profile, reasons for buying, type of nets preferred, use of nets, place of purchase, income, geography, malaria vulnerability, etc.

Insecticides for the treatment of netting, on the other hand, are less likely to be readily available. Affordability of ITMs is a function of two basic parameters: how much nets and insecticides cost, and how much people want them, as shown in Box 3-3.

Appropriate Use Before an ITM program is instituted, information should be gathered on the following topics. ITMs may not turn out to be an appropriate intervention for that particular locale.

Malaria status Actual incidence of malaria. (Could fevers and other malaria-like symptoms actually be caused by something other than malaria?)

Modes of transmission. Behaviors of mosquitoes and other vectors; biting patterns.

Behavioral factors Health and sleeping practices, particularly of marginalized groups (seasonal workers, farmers, nomadic people, construction workers, peri-urban populations, other people who regularly or traditionally sleep outside an enclosed house, and in particular, those people who are not covered by "regular" health services).

Perceptions People's perception of the threat of malaria. Their understanding of the etiology of the disease.

Institutions Community and institutional structures, including the commercial sector, capable of handling a new program (this is particularly relevant for retreatment programs).

Malaria control programs A malaria control program in place with which an ITM program could be integrated. (Interaction between the public and private sector needs to be fostered.)

Operational conditions Health infrastructure already in place to establish and run an effective ITM program.
The topics above concern the appropriateness of ITMs as part of a malaria strategy. But appropriate or proper use of ITMs on the household level must also be considered (see Box 3-4).

The questions listed in Box 3-4 have not yet been answered on any national scale, except in Afghanistan, Gambia, and Vietnam, where comprehensive studies and surveys have been conducted.

The methods, tools, and techniques that are most needed to develop an ITM program must include both routine government statistics and other types of surveys, including qualitative information gained through focus group discussions; assessments of knowledge, attitudes, practices, and beliefs (KAPBs); and other consumer-based information-gathering techniques. It is not appropriate to focus solely on individual access; there is always a need for community-level data.

Box 3-4: Information Needs for Assessing Appropriate Use

Do people now using nets know how to use them properly to control mosquitoes and other vector-borne diseases? What do people use now to control mosquito bites? Who uses nets? Mothers? Children? Heads of households? Pregnant women? Where do people sleep? When do people use nets? Is there a difference in net usage between people in rural areas and urban areas? Does the population know how malaria is transmitted and how it can be controlled? If curtains or door covers are now used, are they used correctly? Are nets treated well? If they are washed, how often are they washed, and are they retreated after washing? Do people know how to properly re-treat nets? How many children under five years of age sleep under nets? Are nets used throughout the year or only during seasons of the year when mosquitoes are most prevalent and a nuisance? Is there a difference between the use of nets by urban and rural populations?

Before research tools and techniques are selected, the objectives of the assessment must be clearly articulated. Research conducted on appropriate use must be relevant and accurate, because research that is conducted poorly or improperly is worse than no research at all. Possible tools and techniques to determine current use of ITMs could include:

Observational visits and household surveys
Focus group discussions to determine knowledge, attitudes, practices, and beliefs
Interviews with users and nonusers
Specific measures of quality control for use, washing, and retreatment of bednets and other ITMs.

Learning by doing is also valuable in instituting new programs because we learn from our experience and we can correct mistakes before a program becomes too large and unmanageable. "Classical" research is not always valuable because it is often conducted in ideal conditions and cannot be used to draw conclusions about what results might be obtained in a real situation.
Box 3-5 lists some of the unresolved issues concerning the assessment phase of programming.

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Planning

While our programming experience with ITMs is limited, our efforts with other health programs associated with child survival (e.g., oral rehydration salts), family planning (condoms and other contraceptives) and HIV/AIDS (condoms and behavior change) give us some insight into issues and approaches that may apply to the planning of ITM activities.

A long-term perspective should be maintained when planning an ITM program. Planners should be considering where people will be getting their nets and insecticides in the future, say in ten years. ITM programs should seek to:

Maximize utilization of ITMs
Minimize dependence on subsidies and external financing
Create a culture of using ITMs
Make netting and insecticides widely available, affordable, and desirable
Spur additional investments in improved technology: e.g., nets that don't need to be retreated or that need treatment less often and individual treatments.

When planning an ITM program, a national committee would need to be set up to bring together and coordinate collaborators from the different sectors. Critical questions that need to be addressed are the respective roles and responsibilities of the public and commercial sectors, NGOs, and donors. Who has the budget response should be figured out in the planning stages. It might be the government or a donor. Planning questions that need to be addressed are who, what, when, where, why, and how. Coordination of information among participants is an important component that has been worked out in the past for polio and other projects.

The first step in planning is to set objectives. Proper planning depends on having:

An accurate definition of key issues, observations, and conclusions
Realistic, achievable, and measurable objectives
A clear understanding of the population to be targeted
Clear roles of all involved in establishing, implementing, and monitoring ITM programs
A partnership working style.

Box 3-5: Outstanding Assessment Issues

Demand Sustainability of demand. Information needs for assessing demand tend to focus on initial demand, not on demand for retreatment or replacement of nets. To assess sustained demand, patterns of use over time (use/repeat use/ dropouts) have to be considered. The combined effects of pricing and availability. What effect do different payment schemes have on demand? What is the relationship between demand creation and the existence of reliable distribution channels? Affordability Lack of experience. Experience is lacking in assessing affordability, and the experience that exists has not been widely documented. It is an absolute necessity to conduct a situation analysis to determine plausible models for assessing affordability. Are ITMs health interventions? Many questions revolving about affordability-especially the question of subsidies-are related to whether ITMs are considered health interventions or commercial products. Bednets can meet public health needs or purely private, domestic needs. Both public health and commercial aspects must be considered; however, dialogue with governments probably won't begin unless ITMs are considered health products (like vaccines). Appropriate Use "Appropriate" in what sense? Health care providers, researchers, and donors may believe that appropriate use of ITMs is making sure that children under age five and pregnant and lactating women sleep under nets as protection from malaria. Focus group discussions have found, however, that people sleep under nets as a way to ward off nuisance bites from mosquitoes and get a good night's sleep. Appropriate for whom? Products may not be appropriate across the board but may be appropriate for different circumstances: for different types of houses, for different family structures, and for different environments. One type of product for all of Africa is inappropriate. Need for effective case management. Effective case management practices should be in place before ITM programs are instituted; that is, appropriate infrastructure and local capacity must be in place to monitor appropriate and effective use of ITMs before any such program is installed.

Demand
Mechanisms typically most successful in promoting demand for bednets cover a wide gamut from radio/TV, street theater, point of sale products (pens, bags), meetings and educational events at churches and mosques, promotion by health facilities, newspapers, school programs (children are future customers), mobile video/films, testimonials by influential persons, and traditional channels (storytellers, singers). If appropriate public institutions use bednetsChospitals, for example, or military posts and boarding schools-that can be a stimulus for wider public demand. This could be the first step in a demand-creation plan. If all hospitals and clinics were using bednets, it would be a huge social marketing message.

Mechanisms/approaches for promoting demand in other sectors (e.g., family planning, water, child survival), including the private sector, are highly relevant to creating demand for ITMs and should be considered when programs are planned. It is not necessary to reinvent the wheel. Appropriate technical support may be brought in to collect information and help design strategies. The process of planning for demand creation is the same for a range of projects. Considerations for planners are given in Box 3-6.

There is no universal recommendation as to what the message should focus on or who it should be directed at. In sum, what is needed is not a canned message but technical assistance and guidelines for formative research and development of a communication strategy.

Accessibility
Few ITM projects have successful distribution systems. Some of the examples from which we can learn are UNICEF/ Ministry of Health projects in Cambodia and Mali; PSI projects in Zimbabwe and the Central African Republic; and the Gambia national project, plus a few others.

Some factors which have made distribution and access successful are:

Buying in bulk which allows leveraging of resources
Working within the existing infrastructure (health and non-health)
Emphasizing local capacity building and supervision at the community level
Absorption of distribution costs by donor agencies
Importing duty free and zero VAT.

Special mention should be made of the importance of retreatment of nets. This is an important, but usually neglected factor for project success.

Box 3-7 gives some key considerations for planners. A distribution method in which products are sold through individuals or door-to-door, and not through stores, may have potential in Africa. Such interactions may offer an opportunity to educate people on the use and benefits of ITMs.

Box 3-6: Key Considerations in Planning for Demand Creation

Appropriate Mix of Approaches The basic options are mass media campaigns and a person-to-person approach. There is a role for both. The appropriate mix depends on the infor-mation gleaned from formative research. With a person-to-person approach it is easier to target geographic segments of the population. Basic Messages Will the basic message be "a good night's sleep" or will it be "protection from malaria"? The two messages call for different strategies; however, it is probable that the mosquito nuisance factor is not sufficient as a motivator. Groups to Target Options for approaches and messages differ for key groups: Consumers messages: sleep well/stay healthy/protect children approaches: education/media/marketing NGOs (local) messages: community service approaches: workshops Community leaders (sellers of corporate products on the local level) messages: productivity/success/status approaches: workshops/focus groups Private sector messages: cost benefit/ profits/public relations approaches: involvement Policymakers messages: improved health/ practicality/ cost-benefit/public appreciation approaches: forums, collaborative programs.

Box 3-7: Key Considerations in Planning for Accessibility

Gender Issues Roles of men and women regarding ITMs will vary. It is important not to make general assumptions about gender roles but to assess gender roles in the project area (decision making, purchasing power, access to outlet, etc.). It is frequently observed that if a household has access to only one net, preferential use will be by the adult male(s), a generally low-risk population. Nets and information on their benefits should be made available to all family members. The role or potential of women in retreatment is an important topic to be considered in ITM projects. Factors that Increase Access Promotion of curtains as well as nets Lowering the price of nets Awareness of community preferences regarding net sizes, materials, etc. Ensure that men, if necessary, have a net. Sustainability Successful large-scale projects have usually had significant donor funding which may create an artificial environment. When donor funding ends, problems are encountered in resupplying nets and insecticides to community groups, and recurrent cost problems may arise. Projects have Asucceeded@ but have sustainability problems.

Affordability
The roles of government and the private sector must be clarified up front during the planning process. These roles, which have an impact on affordability, may change over time. Two dynamic processes are involved in planning: the commercial development of the plan and the national strategy. The national strategy can look at various distribution strategies, including commercial ones. The objectives of the two processes should be parallel and not at cross purposes.

Affordability can be impacted at all levels of the production and distribution chain, from the manufacturer to the wholesaler to the retailer. Some things that could lower costs include:

Tariff reductions
Subsidizing research and development (there are examples of this in the nutrition field and tropical drugs)
Subsidies or cross subsidies (such as was done in the marketing and packaging of condoms)
Bulk warehouses
Economies of scale in manufacture
Well-organized distribution systems
Mechanisms to cut down on theft
Credit schemes.

Many factors must be considered in deciding whether or not local production will bring prices down. If nets are to be manufactured locally there must be available capital, raw materials, infrastructure, and expertise. Manufacturing locally has the advantage of providing local employment. A microenterprise (as in the case of the Benin Women's Coops) might be established and bulk materials could be assembled locally.

Box 3-8: Key Considerations in Planning for Affordability

What is the target group? Who should be involved in the planning process? Will the prices be set and, if so, how? Will a committee set prices? What will the cost structure look like and how may it change over time? What will be done if the nets are not affordable? What is Plan B? Will financing schemes be arranged at the household or community level?

Price is determined by many factors including taxes and tariffs, which also add delays and red tape. If the intent is to protect local industry, then low or reduced duties on raw materials should be established. Local value added tax (VAT) or surcharges must also be considered. If nets are considered a health product, what local VATs are there and would it make sense to lower them?

Another key issue is the advisability of subsidies. ITMs can be made more affordable through subsidies; however, they raise questions of sustainability. To some extent, most bednet programs are subsidized since the price of the net and the insecticides paid by the customer does not reflect the true cost of delivery of the product. The price does not include the costs of training, management, project planning, evaluation, and the like. If these "hidden costs" were included, the price of bednets would go up substantially. Because programs are likely to grow once they get established, it may be possible to plan for subsidies initially and to phase them out later.

The need for subsidies varies by socioeconomic group. Often people who most need the nets are the least able to afford them. The top socioeconomic group can afford to buy the nets at the market price. Middle and lower groups can afford to buy the nets at cost or some fraction of the cost. The number of people needing subsidies is closely linked to socioeconomic conditions in the project area.

In Eritrea, for example, the government was not able to distribute nets free of charge because of the expense. There had to be a cost recovery program. In Kenya, there is no standard pricing policy, and in general, nets are very expensive.

Credit schemes providing up-front financing for nets and insecticides should be made available, including extended payment schemes, wage deductions, borrowing from revolving funds, in-kind payments, incentives, vouchers, community schemes. For example, the community could pool its resources to buy the nets and hold a lottery to distribute them. Eventually the entire community would be covered. In sum, it is important to think creatively about ways to address the economic stresses families may be under.
Box 3-8 lists key questions to be answered in planning for affordability.

Appropriate Use
Lessons learned from other projects can be successfully adapted to promote appropriate use of insecticides and mosquito nets. Separate promotional programs need not be developed. For example, other social marketing programs (promotion of condom use) have been successful. Men can be convinced of the economic benefit of providing bednets for the whole family because they will spend less money later for malaria medicine, and the whole family will be healthy enough to contribute to farming and other income-generating activities.
Information packets and promotional campaigns can be developed for ITMs, and community-level promotions can be developed to promote the use of ITMs. Ultimately, however, responsibility for promotion rests with the Ministry of Health and other national-level authorities.

Planning for appropriate use must begin with an understanding of users and what they wantChence the importance of formative research.

Box 3-9: Key Considerations in Planning for Appropriate Use

The most successful approaches for promoting the appropriate short-term use of bednets and insecticides should be based on what people want. Short-Term Approaches ITMs should be distributed free of charge (at least initially). ITM products should be demonstrated to advertise and promote their use. Distribution programs should be vertical, that is, they should not be a part of a study of vector control techniques. Short-term use should stress the immediate relief from nuisance bites by offering a good night of sleep. Long-Term Approaches User fees could be instituted for cost recovery. ITM programs could be integrated with other health programs and community-based health projects. Messages should be expanded from stressing immediate relief from mosquito bites to explaining how use of ITMs can help control malaria and how nets should be maintained, washed, and retreated.

Box 3-10: Outstanding Planning Issues

Public/private role. Both the public and private sectors have important roles, and the two must work in harmony for an ITM program to be implemented successfully. Sustainability of demand creation. There is a difference between initially motivating and sustaining demand, or creating a culture of bednet use and reuse; the desire for nets is stronger than the desire for retreatment. There may be a need to market insecticides as well as nets. Demand and accessibility. Ongoing access/availability to meet individual demand is an essential aspect of creating demand. If ITMs are not available, the resources poured into creating demand may be wasted. Timing. Timing of a program is very important. Scale. So far, ITM projects have been on a small scale. It would be a good idea to strive for a large-scale national, commercial, high-volume media campaign with adequate budget. Competition. Does competition affect demand generation? Does it have the potential for bringing prices down? Diversification of choice of products. Could ITMs be more affordable if a range of products was presented, such as curtains or different standards of nets? What about retreatment options? Could nets be pretreated before distribution? This could be a faster process and possibly cheaper because nets could be treated in bulk. Promoting new product development. Some examples were fizzy tabs (which were developed for agriculture use), insecticide soaps, and frequent wash sachets.

Implementation

The goal of implementation is to establish a sustainable, long-term ITM program to reduce malaria and mortality and their consequences. Implementation must be realistic. Scaling-up to larger programs must be a gradual process. Mistakes will probably be made. As with any new program, trial and error will yield useful information. To be effective, bednet and ITM programs must be integrated with other disease control programs. National authorities (particularly ministries of health) must assure that ITM programs are coordinated with other disease control efforts.

Demand
Roles and responsibilities of individual sectors in creating and sustaining demand vary during implementation.

Private Sector Role

Provides quality product: good quality control, adequate packaging, clear instructions for use, etc.
Includes health promotion in advertising
Collaborates with demand-creation activities
Works in partnership with NGOs and district health management teams
Continues operational research to evolve strategies for demand creation and appropriate and effective use.

National Government Role

Develops policies and legislation supportive of ITM programs (e.g., import fees, tariffs, and VATs, appropriate standards for use of insecticides, etc.)
Maintains a fully functional health system
Facilitates education
Facilitates supply
Regulates standards of materials
Deregulates markets, e.g., define standards but allow for open movement of product
Trains village health workers
Provides guidelines for community health education.

Box 3-11: Key Government and Private-Sector Roles in Implementation

Government Exercises leadership in ITM programs Reduces taxes and import fees Assures access to ITMs for poorest communities Maintains standards. Private Sector Provides quality product Keeps product affordable Collaborates with demand creation Supports operational research Cooperates with government and NGOs in improving distribution.

Donor coordination during implementation is an important issue. Setting up a national committee for ITMs can be a way to keep all groups involved from working at cross purposes. This is a role for the national government.

Access
Many examples can be found of private sector distribution of insecticides through agrochemical or pharmaceutical networks. One problem with private sector distribution networks is that remote locations may not be reached or served. Another problem is the

Difficulty of controlling prices due to mark-ups at each level. This affects the ability to provide access to poor communities.
To improve distribution networks, public and private sectors should improve collaboration and work toward common goals.
The private sector has the responsibility to provide and promote re-treatment of nets.
Governments should assist the private sector by:

Facilitating the registration of insecticides
Reducing taxes on nets and insecticides
Working with private companies in promotion and training
Assuming responsibility for ensuring access to poor communities.

Smooth implementation of ITM programs depends on supportive government regulations. In other words, the fewer hoops manufacturers and distributors have to jump through to get nets and insecticide to the country, the faster the goods will reach the market.

Affordability
Private sector manufacturers of nets, insecticides and other inputs for ITM programs can lower the cost and thereby increase the affordability of their products. Key factors in keeping costs low are to buy in volume, to standardize, and to plan. Although "one size fits all" doesn't work, some standard guidelines can be followed, depending on the area covered. Also different shapes and sizes of nets could be offered. Basic planning helps in that the longer the lead time, the better. The lack of lead time increases the cost of distribution. Also the type of nets-shape, color, and style-impact cost.

How can manufacturers develop the market for ITMs? Some ideas include incentive schemes, promotional trials (such as sample trials), multi partners (i.e., public relations and research), credit schemes (whereby the first load would be paid for by the manufacturer), customizing or varying packages and sizes, and supporting research.

Assuming that there is broad scale implementation of net programs, the private sector will become larger scale; people will be able to afford more because there will be a stronger economy down the road, and there will be less need for donor support. But there will always be a role for government support to assure equity.

Both government and private sector policies must be flexible in the setting of prices for bednets and other ITMs.

Appropriate Use
ITM programs must continuously reinforce and adapt concepts of IEC (information, education, and communication).
An ITM program must be correctly introduced into a community in order to promote ownership and participation.
Training components must include different messages for different groups of people:

People who handle insecticides and retreat nets must be trained in safety techniques and proper disposal of poisons.
Supervisors and managers of ITM programs need comprehensive training in malaria control, integrated health management concepts, monitoring, reporting, and program evaluation.

Above all, training must be participatory, be based on demonstrations, and must employ repeated and new information. Basic advertising techniques have shown that people respond well to simple messages with a gradual introduction of new and complex educational material.

Opportunities currently exist to integrate ITM training at a variety of levels: as a part of the training for district health workers; as part of basic child survival education for mothers; as a supplement to antenatal care programs; in school curricula; at traditional village events; and as part of microenterprise development projects (women's groups, for example, may be convinced of the economic value of sewing and repairing nets).

Monitoring and Evaluation

Monitoring and evaluation consists of ongoing monitoring of program effectiveness and evaluation of program results. Before a monitoring and evaluation system is established, the following questions must be answered:

What health and management information systems are needed?
How will information be used for decision-making?
How will progress and impact be measured?

Monitoring takes place on four levels impact, outcome, process, and inputs:

Impact: information on morbidity and mortality
Outcomes: information on demand, availability, affordability (price and equity), and appropriate use.
Process: information on how results are to be achieved (program design)
Inputs: information on resources required.

Impact and outcome indicators can be defined in the abstract, but process and input indicators depend on the program design. Box 3-12 below gives sample indicators by theme.

Box 3-12: Sample Indicators for ITM Programs

Demand sales and distribution data retreatment rate consumer satisfaction patterns of use over time (by season). Accessibility proportion of target population for whom nets and retreatment are consistently available within a specified distance from home. Affordability proportion of target population that can afford to obtain a treated ITM and retreatment product. Appropriate Use entomologic susceptibility proportion of target population who slept under an effectively treated net frequency of washing impact (mortality and morbidity).

Monitoring can provide planners with information about the balance between public sector and commercial provision of nets. Periodic feedback on health, rates of malaria, household income, amount of resoaking of nets, and so on will assist planners to make changes in program design.

ITM programs must be linked with larger government programs and incorporated into existing health information systems. Before ITM programs are introduced, there must be at least some basic infrastructure to measure control of malaria.

National and regional authorities ultimately have the major responsibility for public health, including malaria control. Costs of monitoring ITM programs should be built in at the planning stage, and program impact should be tracked through national health information systems. However, nomadic populations, internally-displaced persons, and migratory workers may be excluded from such statistical-gathering efforts. Donors and NGOs should assure that their programs are in accord with national policies.

In addition to the indicators listed in Box 3-12, the following information on community accessibility could be gathered:

The number of people with technical knowledge of nets/insecticides within the community
Access to gloves, adequate safety equipment (also includes environmental disposal methods for packaging)
Outlets, nets, and insecticides per catchment area, per capita, and/or geographical population
Information on Astock-outs@ in outlets; or how often ITMs are not available for purchase
Local groups/institutions involved in promotion/distribution (health centers, shops, churches, NGOs, etc.).

In collecting this information, seasonality factors must be taken into account.

Affordability
Percentage figures will give information about coverage, but it is also necessary to look at who's buying and who isn=t. If people aren't buying nets and insecticide, an attempt should be made to find out why not. The number sold alone provides no information on whether or not the ITMs have reached the target groups.

It is important to monitor prices and to provide feedback to planners. Also the way costs are structured should be monitored. Costs of ITMs and overhead should be kept low. The costs of implementation should also be monitored. If implementation costs are too high, the program may be unsustainable.

Subsidy schemes, scheduled phase outs of subsidies, and financing should be evaluated. What has been the effect of such schemes on the ITM market and on the unsubsidized ITM market? Too large a subsidy could destroy the market.

Appropriate Use
Some programs use the percentage of target groups sleeping under adequately treated nets as an indicator of appropriate use. Indicators should consider these types of topics:

Under five mortality (Are there trends in levels of morbidity and mortality associated with the use of ITMs? How many children's lives are we saving?)
Overall morbidity data
Individual perceptions of the usefulness of ITM programs.

It may be best to use a sentinel site as an indicator of ITM program effectiveness. To do this, however, may require that health information systems be strengthened, particularly at the national level.

Ultimately, an indicator of whether or how well an ITM program is working will be evident in overall community compliance (that is, if a community participates in statistics-gathering, and continues to pay for their nets and insecticides, that, then, is the indicator of how well the ITM program is working).

The following indicators may also yield useful data on appropriate use:

What is the frequency of insecticide retreatment?
How many people live in a household? How many nets does the household have, and who sleeps under them?
What is the proportion of people in the household who sleep under nets?
What is the frequency of net washing?
How many additional, unused nets does a household have (for visitors and other, unexpected needs)?

Obtaining data on these indicators is not easy. Focus group discussions and household observations are useful but are not always practicable. Involving the private sector in collecting data would yield significant data-for example, through the use of sales receipts-but manufacturers and retailers have no incentive to provide such data.

Costs for research to adapt and improve methods of collecting monitoring and evaluation data must somehow be fit into overall program budgets.

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