18 Million Nets and Counting

The Global Fund to Fight AIDS, TB and Malaria (GFATM) has delivered more than 18 million insecticide-treated bed nets as of December 2006. In Malawi alone, UNICEF reports nearly 4 million nets distributed since 2002 from various sources. During a campaign in May 2006, 2 million nets were distributed in Niger through IFRC, CIDA and GFATM support. It is hard to know exactly how many ITNs/LLINs have been distributed in Africa, but in any given year nearly 50 million children under five years of age and pregnant women need protection from malaria.

But is counting nets distributed the right approach? The ultimate test is whether those for whom the nets are intended actually sleep under them.  One of the most crucial problems facing Global Fund grantees is monitoring and evaluation, not only of nets purchased, but generally keeping track of malaria interventions in their countries.  Integrated and functional national health management information systems are rare.

Monitoring is possible though, and on the positive side the President’s Malaria Initiative reported that in early 2006, PMI and the Global Fund distributed more than 230,000 ITNs in Zanzibar, which subsequently saw a dramatic decrease in reported malaria cases and quicker recovery for those infected. According to PMI, the number of confirmed malaria cases on Pemba Island dropped 87% from January to September in 2006.

On the negative side, not long after the net campaign in Niger, the LLINs distributed began appearing for sale in the markets of Kano, Nigeria, just to the south. In addition social research in Ghana and Nigeria revealed that communities often believe that working adults, particularly males, are more vulnerable to malaria, more severely affected and thus, more in need of nets. These perceptions threaten net access within households.

Two key issues must be addressed to ensure bednets reach the intended beneficiaries. First is donor coordination, and second is community education and follow through. Many groups are getting on the malaria bandwagon these days. The newly formed “Malaria No More” featured prominently at the White House Malaria Summit from where it solicited donations for bednets. A visit to its website shows that fortunately MNM is not going it alone, but will be working through UNICEF and IFRC, which already have the infrastructure in endemic countries to get nets to those in need.  Similarly JICA channels most of its net donations through UNICEF.  These efforts help get nets into endemic countries in a coordinated fashion. Likewise on the ground, coordination is needed among the various players. Reports from Zambia, Malawi and Tanzania show that events such as national Child Health Weeks provide an opportunity for all partners to work together to provide nets.

The second issue, education and follow through, links directly with the need for accountability in achieving Roll Back Malaria usage or coverage indicators, which now aim for 80% of vulnerable groups sleeping under nets by 2010.  IFRC provides a toolkit (worksheet) for local chapters involved in net distribution that includes key messages about malaria and nets as well as directives on the need to demonstrate appropriate use to community members. The toolkit guides volunteers to monitor net use and report results.  Recently we reported here that using community-directed intervention with local volunteers produces substantially better net acquisition and use than typical health department distribution efforts. Local volunteers selected by the community are better able to communicate and monitor health interventions because they live with the people and understand culturally appropriate ways to communicate health information including issues of vulnerability to malaria.

Recently the Executive Director of Church World Service addressed the intentions of governments and donors by noting that, “For those children who suffer the ravages of malaria, promises that come and go mean absolutely nothing, only action makes a difference.” Hopefully by this time next year we are not counting promises to distribute nets ¾ or not even counting nets distributed ¾ but counting the number of children and pregnant women actually sleeping under those nets and lives saved.

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