Dr Abdul Wasi Asha

President, Institute of Malaria and Parasitic Diseases

Ministry of Health, Transitional Islamic Government of Afghanistan

Inter-country Workshop on Scaling-up ITN Implementation for Control of Malaria

and other Vector-Borne Diseases in Countries of EMR

Abha, Kingdom of Saudi Arabia18-20 October, 2003

Roll Back Malaria and Cutaneous Leishmaniasis Control Program for

Afghanistan

Afghanistan’ ITNs Strategy(2004-2008)

Challenges • Delays in establishing the proposed primary health care system. 65% of

the population have limited or no access to formal health care

• Logistic barriers including limited road access to many parts of the country

• Confusion over the integration of a historically vertical programme into community-based and district health care services

• Bias towards curative care delivery by health services and decision makers

• Health services are supported by a multitude of partners, creating occasional difficulties for coordinated approaches

• Low incentives for government staff forcing competent staff to supplement their income through private practice or seek employment in the private, NGO or UN sectors where income is higher

• Limited mobility of women (as health workers, household decision makers, and patients)

Challenges (cont’d) • Limited data for planning and monitoring purposes (the national

Health Information System has not operated since 2001)• Limited knowledge and understanding of malaria among some

sections of the population (including some health workers)• Low purchasing power among some population groups with

regard to ITNs• Absence of private sector participation to expand ITN sales• Ongoing insecurity and political instability in some areas. • Ongoing population and health worker preference for indoor

residual house spraying and other chemical methods of vector control other than ITNs for malaria prevention.

• Scale of input (material, financial and technical) to achieve coverage is large.

Afghanistan’ ITNs Strategy(2004-2008)

Assumptions:• That security in Afghanistan will steadily improve, and that

political stability will be attained.• That there will be continued external support to Afghanistan

over the next 5 years. Support includes material, financial and technical and comes from a variety of sources including bilateral donors, multilateral agencies and international NGOs.

• That supply of WHOPES approved LLINs will meet the global demand by the end of 2003

Afghanistan’ ITNs Strategy(2004-2008)

VISION:• At least 60% of the target population in Afghanistan sleep

under insecticide-treated nets during the transmission season by the end of 2008, resulting in reduction of malaria and anthroponotic cutaneous leishmaniasis transmission.

• In urban areas, the majority of the target population will purchase ITNs and home treatment kits from the unsubsidized commercial market, and vulnerable groups will obtain subsidized ITNs and home treatment kits from the public sector and NGOs.

• In rural areas ITNs be promoted and distributed using community mobilisation strategies, closely linked to the implementation of community-oriented primary health care system. ITNs will be made available to all affected members without attempt at full cost recovery, and distribution should be highly subsidised or free of charge where appropriate.

Afghanistan’ ITNs Strategy(2004-2008)

• External support including donor funding will be sought to assist in achieving coverage amongst vulnerable and rural communities, as well as pump-priming the private sector.

• Recognizing the country’s current weak health infrastructure, the implementation of this strategy at the grass-root level will depend to a large extent on the NGO’s network through an established National Steering Committee (Chaired by the MOH) as well as the mobilisation of the local community. As the health infrastructure and security improves, attempts will also be made to strengthen the capability of the public sector (MOH) to play a leading role especially in providing a conducive environment and in addressing

issues of equity.

Afghanistan’ ITNs Strategy(2004-2008)

GOAL: Contribute to the reduction of malaria and anthroponotic cutaneous leishmaniasis disease burden in Afghanistan

STRATEGIC OBJECTIVES: Increased use of ITNs by all household members in targeted areas endemic for malaria and anthroponotic cutaneous leishmaniasis

Afghanistan’ ITNs Strategy(2004-2008)

PRODUCTS and ACTIVITIES

• Outcome 1: 60% of target population will be protected by ITNs through adoption and implementation of effective strategies by the end of 2008

• Mechanisms for identifying target population are developed.

• Public/private, private/private partnerships are built.

• ITN distribution systems and mechanisms are established.

• ITN promotion plan is developed, using communication for behavioural impact (COMBI) methodology.

• Models and guidelines for targeting subsidies are established.

• Procurement strategies are developed.

Afghanistan’ ITNs Strategy(2004-2008)

• Outcome 2: 80% of nets used by target populations are effectively treated with insecticides by the end of 2008

• Initial treatment is ensured.

• Accessible and functional treatment / retreatment centres are established.

• Treatment and re-treatment promotion plan using COMBI methodology is developed.

• Distribution mechanisms/systems for free insecticides are developed.

• Distribution mechanisms/systems for individual use (treatment kits using social marketing or private marketing) are developed.

Afghanistan’ ITNs Strategy(2004-2008)

The Partnership Development Process

• Establishing a National Steering Committee for ITN implementation:

• Chair: MOH

Members: HNI, UNICEF, WHO, PSI, USAID

• Invited members: Ministry of Education, Ministry of Information, Chamber of commerce, Ministry of Finance, Ministry of Agriculture, Provincial MOH representative (1).

Terms of reference

• Identify target population

• Coordinate ITN programming and implementation

• Create strong political support

• Advocate for resource mobilisation and soliciting human and financial resources

• Lobby for the removal of tax and tariff barriers

• Coordinating ITN promotion

• Plan mechanisms for targeting subsidies

• Monitor and evaluate implementation for continuous improvement

• Set priorities for operational research

• Establish a network of provincial coordinating committees

• Develop detailed yearly implementation plans specifying targets, indicators, and partners

• Present recommendations and progress reports to Country Coordinating Mechanism for GFATM

Afghanistan’ ITNs Strategy(2004-2008)

• Establishing or reinvigorating the provincial coordination mechanisms

• The National Steering Committee should ensure the establishment of the provincial coordination mechanisms

• Provincial coordinating mechanisms should build on existing coordination mechanisms where possible, such as sub-national CCMs of the GFATM, health coordination committees, and malaria working groups

• Provincial coordinating mechanisms should be inclusive of all partners working or potentially working in malaria control, including for example WV, IMC, Malteser, Merlin, SCA, MSF, Ibn Sina, AMI, Mercy corps

Afghanistan’ ITNs Strategy(2004-2008)

• Partners:• Alongside the MOH, UN agencies and HNI, a further 22

partners have been, are, or will be involved in implementation of ITNs in Afghanistan:

• Swedish Committee of Afghanistan (SCA); Hewad; QLC; ORA; MCI; ISRA; Ibne Sina; IAHC; Aryan; Habitat; DAC; ATA; ARCS; AMI; AHDS; TODAI Japan; World Vision; Save the Children – US; Merlin; Malteser; and Population Services International (PSI).

Afghanistan’ ITNs Strategy(2004-2008)

2. Roles of the partners:a. Public sector• Create enabling environment for all partners• Mobilise resources• Promote generic demand through use of a variety of approaches and

channels• Coordinate and chair the ITN steering committee and the

involvement of partners in scaling-up coverage• Agenda-setting for operational research, through the steering

committee• Set standards and norms for ITNs and insecticides, monitor and

regulate their quality• Ensure equitable distribution and access to ITNs • Coordinate, through the IEC department of the MOH, an effective

national social mobilisation and communications for behavioural change programme to ensure correct utilisation and monitor usage of ITNs

• With partners, monitor and evaluate efforts to scale up effective ITN coverage

Afghanistan’ ITNs Strategy(2004-2008)

b. Private sector• Create awareness and demand for branded net and

insecticide products• Improve product image and acceptability through consumer

research• Surveillance and monitoring of the commercial market• Supply, in a sustainable manner, ITNs and insecticides for net

re-treatment• Equitable distribution of ITNs, including through targeted

subsidies for those most vulnerable to malaria in accordance with the National Steering Committee recommendations

• Execution of social marketing schemes to generate demand for generic net and insecticide products

• With partners, monitor and evaluate efforts to scale-up effective ITN coverage

Afghanistan’ ITNs Strategy(2004-2008)

• c. Non-governmental Organizations (NGOs) and civil society

• Equitable distribution of ITNs, including through targeted subsidies for those most vulnerable to malaria in accordance with the National Steering Committee recommendations

• Execution of social marketing schemes to generate demand for branded net and insecticide products

• With partners, execute a programme of communication for behavioural impact for correct usage of ITNs

• With partners, monitor and evaluate efforts to scale up effective ITN coverage

• Conduct of operational research in line with priorities set by the National Steering Committee

Afghanistan’ ITNs Strategy(2004-2008)

d. Multi-lateral agencies and donors• Provision of technical support for development of guidelines

and standards • Advocacy for prioritisation of ITN programmes for the

prevention of malaria and other vector-borne diseases within the health sector

• Resource mobilisation• Capacity building of MOH• Advocate, internationally, for the removal of taxes

Afghanistan’ ITNs Strategy(2004-2008)

• Operational research. • To ensure the evidence base of the ITN strategy, several areas are

identified for operational research:

• Consumer preference studies.

• Polyethylene Olyset® net effectiveness in preventing anthroponotic cutaneous leishmaniasis (ACL).

• Epidemiological impact evaluation.

• Cost-effectiveness of ITN programme implementation.

• Socio-economic burden of malaria..

• Level of ITN coverage needed to achieve public health impact.

• Market surveys.

• Update of important vectors of malaria.

• Health worker and household case management

Afghanistan’ ITNs Strategy(2004-2008)

THANK YOU