Microsoft word - frameworkstrategicoptions.doc

DRAFT
A framework of strategic options
For the integrated delivery
Insecticide-treated nets and immunization
London School of Hygiene and Tropical Medicine, and Jenny Hill, Child and Reproductive Health Group Liverpool School of Tropical Medicine and Hygiene. This document will be technically edited and
published in English by May 2006
Acknowledgements

This framework, commissioned by WHO, was written for the Global Malaria Programme
by Jayne Webster, TARGETS Consortium, London School of Hygiene and Tropical
Medicine, UK, and Jenny Hill, Child and Reproductive Health Group, Liverpool School of
Tropical Medicine, UK. The authors wish to thank all individuals who provided
documents and contributed information from their own experiences.
The views expressed in the paper do not necessarily reflect the policies of WHO and
statements regarding countries, their borders and populations do not imply the
expression of any opinion on the part of WHO. This document should not be quoted or
disseminated without the agreement of WHO. Queries should be addressed to Dr M. K.
Cham, Global Malaria Programme ([email protected]).


Acronyms
ACSD
accelerated child survival and development Bacille Calmette-Guérin (vaccine against tuberculosis) Community Based Malaria Prevention and Control Programme Canadian International Development Agency Global Alliance for Vaccines and Immunization Global Fund to fight Tuberculosis, AIDS and Malaria Deutsche Gesellschaft fur Technische Zusammenarbeit Haemophilus influenza type b vaccine International Federation of the Red Cross and Red Crescent Societies Integrated Management of Childhood Illness intermittent presumptive treatment for pregnant women London School of Hygiene and Tropical Medicine tetanus toxoid vaccine (TT1 = first dose, TT2 = second dose etc) Table of contents

SUMMARY 7
1. INTRODUCTION
1.1 Goals and targets
1.2 Immunization delivery: schedules and rationale
2. MODELS OF INTEGRATED DELIVERY OF ITNS AND IMMUNIZATION
2.1 Integration of ITNs with routine immunization services
2.2 Integration of ITNs with expanded routine child health services
2.2.1 Child Health Week / Child Health Days 2.3 Integration of ITNs with vaccination campaigns
3. OUTPUTS AND OUTCOMES OF INTEGRATED DELIVERY MODELS
3.1 Routine systems
3.2 Expanded routine
3.3 Campaigns
4. CONSIDERATIONS IN SELECTING STRATEGIES FOR INTEGRATION 27
4.1 Target groups
4.2 Current coverage of ITNs and delivery systems for ITNs
4.3 Current coverage of EPI
5. ISSUES IN PLANNING, IMPLEMENTATION, MONITORING AND
EVALUATION 30
5.1 Opportunities and challenges of specific models
5.2 Cross-strategy issues in planning, implementation, monitoring and evaluation
6. PARTNERSHIPS
6 .1 Key partnerships spearheading integrated campaigns
6 .2 Partnership Coordination for integrated campaigns
6 .3 Partnership lessons
REFERENCES 47
Summary

The World Health Organization (WHO) and the United Nations Children’s Fund
(UNICEF) have recently published a joint statement on their commitment to developing
more integrated programming approaches between malaria control and immunization.
National malaria control programmes and their partners are showing increasing interest
in joining WHO and UNICEF in their proposed integrated approach to insecticide-treated
net (ITN) and immunization programming. Reviews of published and grey literature were
undertaken, as were three country visits, in order to analyse and collate past, current
and planned integration experiences.
Three types of integrated delivery of ITNs and immunization are defined. These are:
routine, enhanced routine, and campaign. They are further categorized by the service
through which they are delivered, for example antenatal clinics (ANC) and measles
campaigns. These categories of service reach varying portions of the malaria target
groups of pregnant women and children under five years. No single category of delivery
system integrated with immunization reaches the full complement of these targets.
Combinations of integrated delivery models are therefore necessary to reach all target
groups.
Scale and duration of experiences has varied between and within the different
categories as has the emphasis on assessment of, and dissemination of, outputs and
outcomes. Experiences of national level implementation are few. Although there is a
general focus on targeting of subsidies on ITNs to pregnant women and children under
five years, blanket subsidies are being delivered in some countries. Insufficient funding
for nationwide delivery through routine systems has resulted in geographical targeting of
ITNs even within malaria endemic areas. Selection of areas for such geographical
targeting has been based mainly on health and poverty indicators.
To date more ITNs have been delivered through routine integrated systems than through
campaigns. There have been no rigorous comparisons of the impact of different
integrated delivery systems. Available data are from evaluations of single systems, using
different indicators and operational definitions of indicators. However, available data
show that global targets have been reached on a small scale (district level) by several of
the models of integrated delivery, including ANC/Mother and Child Health clinic (MCH),
intervention packages, and measles campaigns. Within national scale delivery, coverage
outcomes vary between districts, some meeting the Abuja targets and others not. No
single model of integrated delivery has yet reached 60% coverage of pregnant women
and/or children under five years at the national level. Evidence suggests that integrated
measles campaigns achieve a greater equity of coverage of ITNs across socioeconomic
groups than do other integrated systems of delivery employed, or assessed, to date.
Standard packages of indicators, instruments, and methods for monitoring and
evaluation of the different models are needed which embrace all opportunities of
collection of rigorous data at the national and sub-national level.
Integrating the delivery of ITNs and immunization through a single system will not
achieve the Abuja targets of 60% of pregnant women and children under five years
sleeping under ITNs. Combining delivery models offers the best possibility for achieving
this goal at the national level and with a minimum level of disparity across districts and
socioeconomic groups. Increased mobilization of resources, effective strategic planning
and partnership coordination are required. Whilst focusing on the integrated delivery of ITNs with immunization, it is important to remember that this group of models is not exclusive. To date, the vast majority of children covered by nets in Africa got these nets through the commercial sector, and these nets are reaching the malaria target groups. The advent of new technologies will enable these nets to achieve the same level of effectiveness as the long-lasting insecticidal nets (LLINs) that are currently in great demand and relatively short supply. 1. Introduction
The World Health Organization (WHO) and the United Nations Children’s Fund
(UNICEF) have recently published a joint statement on their commitment to developing
more integrated programming approaches between malaria control and immunization
(1). The statement emphasizes that although collaboration has been limited to date,
there is scope for exploring, developing and expanding across health programme
synergies within the context of going to scale with national insecticide-treated net (ITN)
programmes. In addition, the 11th and 12th Meetings of the Task Force on Immunization
in Africa requested WHO to facilitate integration of immunization activities with other
interventions such as ITNs, and deworming. The Task Force further recommended the
development of technical guidelines for integrated programming of maternal and child
health services, including monitoring and evaluation. Potential areas for collaboration
identified were: delivery; social mobilization and education; geographical
reconnaissance, surveying and monitoring; and training and supervision. National
malaria control programmes are showing increasing interest in joining WHO and
UNICEF in their proposed integrated approach to ITN and immunization programming.
A review of published and grey literature was undertaken together with visits to three
countries, namely Ghana, Kenya and Zambia, in order to gather information on country
experiences relating to the integrated delivery of ITNs and immunization. This document
synthesises the findings of the review in the form of a conceptual framework of strategic
options for the integrated delivery of ITNs and immunization; the specific findings of the
review are presented elsewhere. The major issues raised by countries with experience
of such integrated delivery are presented together with potential solutions based on the
available evidence. The document aims to provide a resource to national programme
managers and other partners supporting the national scale-up of ITNs through integrated
programming with immunization.
1.1 Goals and targets
Malaria and Expanded Programme on Immunization (EPI) programmes have defined
global goals and targets for ITNs and for immunization respectively, but integration of
delivery systems for both interventions will require use of combined targets to guide
programme strategy.
1.1.1 Malaria target for ITNs
The goal of the Roll Back Malaria (RBM) initiative is to halve the burden of malaria by
2010. ITNs have been shown to reduce the number of child deaths by about one-fifth,
saving around six lives for every 1000 children under five protected per year in sub-
Saharan Africa (SSA). Targets to reduce child mortality established at the Abuja Malaria
Summit in April 2000 therefore include a target for ITNs (2). Coverage of ITNs across
many countries is however currently unacceptably low and the scale-up of coverage is
vigorously being promoted by RBM. An RBM consensus document on ITN scale-up (3)
suggests that the way forward for achieving and sustaining high level coverage with
ITNs is a two-pronged approach: sustained and targeted subsidies for the most
vulnerable, to promote equity, balanced with efforts to create an enabling environment to
support expansion of the private sector, to promote sustainability.
1.1.2 Immunization targets
The EPI was launched by WHO in 1974, at which time less than 5% of the world’s
children were immunized against the six target diseases selected for inclusion in EPI. In
1984 the Universal Child Immunization (UCI) initiative was launched to accelerate EPI with target coverage of 80% for all six antigens. UCI was declared by UNICEF in 1990. However, the reality was that the 80% coverage achieved reflected high coverage in some relatively heavily populated countries (4) , masking very low coverage in other countries. The aggregated data hid the reality that 107 countries had not achieved universal coverage (5), and the fact that there were significant intra-country disparities in coverage. After 1990, there was a call to reach target populations that had not been immunized and the coverage goal was raised to 90% (for all six antigens). In acknowledgement of the distributional concerns over coverage, the Global Alliance for Vaccines and Immunization (GAVI) set a goal that 80% of developing countries should have routine immunization coverage (with three doses of diphtheria-tetanus-pertussis vaccine [DTP]) in at least 80% of all districts by 2005 (6). By 2010 or sooner, the goal of routine EPI immunization is 90% national coverage (with three doses of DTP [DTP3] in children one year of age), with at least 80% coverage in all districts1. In May 2005, governments at the World Health Assembly welcomed the launch of a new “Global Immunization Vision and Strategy” (GIVS) developed by WHO and UNICEF. The GIVS offers a unified vision of immunization and a set of strategies to meet the immunization challenges of the coming decade. GIVS has three main aims: to immunize more people against more diseases; to introduce a range of newly available vaccines and technologies; and to provide a number of critical health interventions with immunization.2 By 2005, 60% of children under-five and pregnant women are sleeping under ITNs By 2010 or sooner, 90% national coverage (with three doses of DTP in children one year of age), with at least 80% coverage in all districts
1.2 Immunization delivery: schedules and rationale
Scaling-up the delivery of ITNs to national level is relatively new in comparison with that
of delivery of childhood vaccination through EPI. EPI has developed a routine schedule
for all children, which is complemented by intermittent campaigns. The schedules and
rationale are presented below. The methods and frequency for delivering ITNs are less
well defined and there is still much debate about the best way to achieve and sustain
national level coverage among target groups.
1.2.1 Routine delivery
Children up to about nine months of age are targeted for routine EPI, although children
above this age who have not completed their course will be immunized. The
recommended schedule of immunizations is presented in Table 1 below. The six primary
antigens are Bacille Calmette-Guérin (BCG), DTP, measles and oral polio vaccine
(OPV). With GAVI support many countries are now introducing new vaccines, often in
combinations containing Hepatitis B (HepB) and Haemophilus influenza type b (Hib).
Measles vaccine and yellow fever (where applicable), are the last of the routine
childhood vaccines and are given at nine months of age.


1 UN General Assembly Special Session on Children 2002 Table 1. Immunization schedule for children
Age
Vaccines

BCG – Bacille Calmette-Guérin; OPV – Oral polio vaccine;
HepB – Hepatitis B; DTP – Diptheria-tetanus-pertussis
Hib – Haemophilus influenza type b
Immunization schedules for protection against tetanus begin in the newborn period
(Table 1), with reinforcing doses of tetanus toxoid (TT) when older. In addition, every
woman of childbearing age (15–49 years) should receive five doses of TT (Table 2) in
order to protect the newborn from neonatal tetanus. A minimum of two doses at least
four weeks apart are required for protection.
Table 2. Tetanus toxoid immunization schedule
Dose
When given
Period of protection

At first contact with woman of childbearing age, or as early as possible in pregnancy 1.2.2 Campaigns
Eradication of polio by the year 2000 was adopted as an immunization goal in 1988.
Intensive efforts continue to interrupt the transmission of poliovirus in the six remaining
endemic countries (Afghanistan, Egypt, India, Nigeria, Niger and Pakistan). The three
strategies of the Global Polio Eradication Initiative include: attaining high routine
coverage with at least three doses of oral polio vaccine; conducting national
immunization days (NIDs); and mop-up vaccination in high-risk areas as identified
through surveillance in areas where polio is reduced to focal transmission. The goal of
polio NIDs is to achieve 90% coverage of children aged 0 to 59 months in polio-endemic
countries.
Polio NIDs aim to interrupt poliovirus transmission through giving oral polio vaccine to all
children in a large geographic area over a short period of time. Therefore special efforts
are needed to reach children who are missed by routine immunization services. During
NIDs doses of OPV are given to children within a defined age group, which is usually 0
to 59 months of age, regardless of their vaccination history. These are considered to be
additional doses and do not replace those received through routine EPI. The aim is to
provide these vaccinations during each round of NIDs in as short a period of time as
possible, and preferably within two days. NIDs are conducted in two rounds and the
second round should take place four to six weeks after the first. NIDs are expected to be
conducted annually for three years after which time polio should be reduced to focal
transmission and NIDs replaced by mopping-up campaigns and sub-national
immunization days (SNIDs) as appropriate.
A global goal to reduce measles deaths by half by the end of 2005 (compared with 1999 levels) was adopted by the UN General Assembly Special Session on Children (2002). The effectiveness of measles vaccine is low in the presence of maternal antibodies which are present up to about six months of age. By the age of nine months, effectiveness of the vaccine is around 85%. The lower age limit for measles vaccination is therefore nine months. If a significant proportion of measles cases are known to have occurred in children between six and nine months of age then children within this age group may be vaccinated. However, they will then need to be revaccinated at nine months of age as below this age the vaccination is only about 50% effective. During measles campaigns, known as Supplementary Immunization Activities (SIAs), all children in the target age group are vaccinated regardless of their history of immunization. Traditionally the target age groups have been 9 to 59 months. However, in many countries significant levels of morbidity and mortality in older children mean that children aged up to 15 years may also be included in the target group. There are recommended intervals between follow-up SIAs dependent upon percentage coverage. Classification of delivery of measles vaccination is presented in the box below. Classification of measles vaccination delivery: ¾ Catch-up Efforts to vaccinate all children aged 9 months to 15 years in order to reduce the numbers of susceptible persons in the population (those never vaccinated and those in whom the primary vaccination failed). ¾ Follow-up Periodic mass immunization campaigns conducted every three to four years following catch-up campaigns to reduce numbers of susceptible persons born since the last supplementary immunization activities e.g. if two years since last campaign — target 9 to 33 months. ¾ Keep-up Maintaining high coverage through routine activities during inter-campaign periods The 42nd World Health Assembly (1989) called for global neonatal tetanus (NT) elimination. Elimination is defined as less than one case of NT per 1000 live births in every district. Areas burdened by maternal and neonatal tetanus (MNT), called high-risk districts (HRDs), typically have very limited health infrastructure. Supplementary immunization activities (SIAs) delivering TT to women of child-bearing age in HRDs have proven to be a cost-effective way to reach and protect these populations. This high-risk approach (HRA) continues to be recommended. Tetanus toxoid SIAs have been implemented in thirty-four countries during the period between 1999 and 2004, and in about eighteen countries in earlier years. To prevent an epidemic of yellow fever, at least 80% of the population must have immunity to the virus. This can only be achieved through incorporation of yellow fever into childhood immunization programmes and implementation of mass catch-up campaigns to vaccinate the entire population older than nine months of age. Protective immunity occurs within one week for 95% of people vaccinated. Measles Supplementary Immunization Activities (SIAs) target: Supplement routine measles vaccinations, target the susceptible and ensure coverage of >90% of children aged 9 months to 59 months, or in some cases 9 National Immunization Days (NIDs) target: 90% coverage in children aged 0 to 59 months in polio-endemic countries
2. Models of integrated delivery of ITNs and immunization
Routine and campaign systems of delivery for immunizations are well defined; however
the same does not apply to delivery of ITNs. There are a multitude of systems to deliver
nets, insecticides and ITNs to households. Many are historical while others have
developed over the last two decades. Within a focus on integrated delivery of ITNs with
immunization we include public sector delivery and mixed (public-private) models, but
pure private sector delivery is excluded. Voucher schemes are an example of a public-
private model where the voucher is delivered through the public sector and the ITN
through the private sector. Whilst excluding pure private sector delivery from this
analysis, we acknowledge that the private sector has been to date the most significant
delivery system for mosquito nets (7). The impact of integrated public sector delivery
systems on commercial ITN markets should be considered when evaluating strategies
for delivering ITNs, as the private sector plays an important role in the sustainable
supply of ITNs to non-target groups.
Models for integrated delivery of ITNs and immunization may be broadly typified as
routine, expanded routine, or campaign. We may then further define each of these types
of delivery system by the category of service through which the end user receives the
ITN (Figure 1). Routine integrated delivery of ITNs together with immunization may be
achieved through services delivering tetanus toxoid to pregnant women (that is, through
ANC), through services delivering childhood vaccinations (EPI), and through
programmes delivering packages of the two together with other child survival
interventions, for example through MCH. So far there are experiences of integrating the
delivery of ITNs through all three types of integrated system (routine, expanded routine
and campaign) but not all categories of service have been used. Child Health Weeks are
being undertaken in a growing number of countries and involve concentrated promotion
and delivery of child health interventions, such as de-worming alongside immunization,
usually during a one-week period. These are not considered to be campaigns but rather
“enhanced routine” delivery, and have been used to deliver both insecticide
(re)treatment and ITNs. Immunization campaigns to which the delivery of ITNs may be
integrated include measles SIAs, polio NIDs, yellow fever and tetanus toxoid.
Experiences of ITN integration with immunization campaigns to date involve only the first
two — for measles and polio.
This section provides a brief introduction to the experiences of delivering ITNs through
ANC, MCH, packages of interventions, expanded routine, and campaigns. It is followed
by a section that gives examples of outputs and outcomes through these systems
(section 3). Issues relating to delivery may differ within each of the three types of
system, and sections 4 and 5 provide a summary of issues to consider when planning
and implementing the integrated delivery of ITNs through these models. Questions being
asked by countries and their partners currently implementing or considering
implementing integrated delivery of ITNs and immunization are addressed. Section 6
describes the partnerships operating at global, regional and country levels, including the
factors contributing to successful partnerships.
2.1 Integration of ITNs with routine immunization services
Routine immunization is delivered through ANC clinics, and through Mother and Child
Health Clinics/ Child Health Clinics (MCH/CHC), each of these offering an opportunity to
reach different ITN target groups. There is more experience to date with targeting the
delivery of subsidized ITNs to pregnant women through ANC than to children under five
through MCH/CHC. Although the main target groups attending ANC and MCH are
pregnant women and children under five respectively, it is also possible to take the
contact opportunity with multigravidae at ANC to reach children under five, and at MCH
to reach pregnant women. A combination of both ANC and MCH/CHC provides the best
opportunity for reaching the majority of the ITN target groups.
2.1.1 Antenatal clinics
ANC offers a good opportunity for targeting pregnant women with the delivery of ITNs
and has been the focus for targeting subsidized ITNs to pregnant women over the last
few years. The delivery of ITNs through ANC has involved two ways of providing the ITN
subsidy: 1) giving a subsidized ITN (i.e., direct product) or 2) giving a discount voucher
which can be exchanged for an ITN at a commercial or other pre-identified outlet. The
level of subsidy for both direct product and vouchers ranges from 100% to 40%.
Figure 1. Typology and categorization of models for integrated delivery of ITNs
and immunization

Routine services
Intervention
packages
Child Health
Weeks/Days
Enhanced
Enhanced
outreach
Campaigns
Key
Pink = some documented experiences
Blue = no documented experiences
Direct product
Delivery of ITNs to pregnant women through ANC is either currently under way or
planned in many countries of sub-Saharan Africa (SSA). In some countries, such as
Cameroon and Ghana, the ITNs are distributed by the National Malaria Control
Programme (NMCP) or its equivalent to districts and from there to peripheral health
facilities. In other countries, partnerships with a social marketing organization are
involved. Population Services International (PSI) is currently supporting the Ministry of
Health (MoH) in ten countries to deliver ITNs to pregnant women and children under five
through ANC and MCH. The scale of these distributions ranges from one district (e.g.
Angola) to national level (e.g. Malawi). The cost of the products to the end user varies
depending on where distribution is undertaken by MoH and where social marketing
organizations are involved. In Cameroon, ITNs are delivered free to pregnant women
through ANC, whereas in Ghana the cost to the pregnant woman is approximately US$
2.20. The cost to the end user of ITNs delivered through ANC and MCH with the support
of PSI varies from US$ 0.40 in Malawi to US$ 2.80 in Angola. The biggest constraint on
these programmes has been the supply of ITNs, which has been predominantly related
to funding availability.
Voucher systems
Voucher systems for the delivery of ITNs to pregnant women, of varying scale and
duration, have been implemented in Ghana, Mali, Senegal, the United Republic of
Tanzania, Uganda and Zambia and are planned in Ethiopia and Nigeria. The design of
these voucher schemes varies but the basic mode of operation is that discount vouchers
are given to pregnant women upon attendance at ANC. The voucher entitles them to a
discount on an ITN available from retail or other designated outlets. Voucher schemes
have been piloted in Ghana, Senegal, the United Republic of Tanzania, Uganda and
Zambia. Scaling-up is now underway in both Ghana and the United Republic of
Tanzania, in seven out of ten regions in Ghana and nationwide in the United Republic of
Tanzania. In Zambia, the vouchers continue to be delivered in ANC “along the line of
rail”, which is the commercial hub of the country covering several districts. In six out of
nine provinces of Zambia, ITNs are delivered as a direct product through ANC at a
subsidized price.
Where data are available the level of subsidy on ITNs delivered through ANC using
vouchers has ranged between 20%–70%, and pregnant women are paying from
US$ 0.60 to over US$ 6.00 for their ITN. Where vouchers are used to deliver ITNs the
woman has a degree of choice (variable depending upon local availability), and therefore
the amount she pays depends upon the type of ITN she selects.
2.1.2 Maternal and child health clinics
Delivery of ITNs to children along with EPI presents an opportunity for reaching children
less than one year. Where EPI is delivered through MCH, children aged 0 to 59 months
may be targeted, together with their mothers if they are pregnant. As with ANC, ITNs
may be delivered along with EPI as a direct product or via a voucher. There are
substantially fewer experiences of delivery of ITNs through EPI than there are through
ANC. The major limitation has been levels of funding in relation to the size of the target
group — that of pregnant women is smaller than that of children under five
(approximately 5% versus approximately 15% of the total population). Delivery of ITNs
through ANC may be considered to have been a pathfinder for the integrated delivery of
ITNs with EPI. The product delivered through EPI varies in some models, such as the
NATNETS programme in Tanzania where ITNs are delivered to pregnant women
through ANC whilst insecticide for (re)treatment of nets is delivered through EPI at DTP3
and measles immunization contacts.
2.1.3 Packages of health interventions
The UNICEF Accelerated Child Survival and Development (ACSD) programme includes
a package of interventions: EPI+, IMCI+ and ANC+. The interventions included in each
category are for EPI+: EPI, vitamin A, and ITNs; for IMCI+: management of malaria,
pneumonia and diarrhoea; for ANC+: ITNs, intermittent preventive treatment in
pregnancy (IPTp), TT, and iron and folate (IFA). This package was initially implemented
during 2002 in selected districts of four countries (Benin, Ghana, Mali and Senegal)
which were termed “high impact” (HIP) districts. The programme has since expanded to
further districts in each of these four countries and to a further seven countries (Burkina
Faso, Cameroon, Chad, Gambia, Guinea Bissau, Guinea Conakry, and Niger). These
new districts are termed ‘expansion districts’ and include an initially reduced range of
interventions including EPI+ and ANC. The total population targeted in the initial districts
of the four high impact countries was 4,321,670, with a further 9,123,588 in the
expansion districts. The total target population including the seven expansion countries
is 20,951,423.
Strategies for delivering ITNs through ACSD vary between countries and certain aspects
of the programme also vary within countries. ACSD is a district-based strategy, however,
in Ghana, as the programme has scaled up there has been some shifting of
responsibility to the regional level. In Ghana, delivery points for ITNs include ANC, Child
Welfare Clinics, outreach, and sales agents. The original plan was for ITNs to be sold
through health facilities, but upon realizing that targeting children through EPI would only
reach those aged less that one year, the strategy was adapted to include sales within
the community through sales agents. The sales agents sell ITNs to all age groups.
However, there is a quota for numbers of ITNs to be sold to the target groups, pregnant
women and children under five (95%), and to the general population (5%).The policy
within both regions implementing ACSD in Ghana is that health facility staff should not
be involved in selling ITNs, but rather that the sales agents should sell ITNs within the
health facilities and within the community.
In Mali the ACSD programme targets pregnant women and children aged 0–11 months
who are given an ITN on completion of their vaccination schedule. Senegal uses the
same target group for ITN delivery, but ITNs are delivered using a voucher system. The
level of subsidy on the ITNs varies in the three countries and, consequently, so does the
amount that the end user needs to pay. In Ghana, ITNs are sold to pregnant women and
children under five for 5000 cedis (approximately US$ 0.60), and to the general
population at 20,000 cedis (approximately US$ 2.40). In Mali, ITNs are delivered free of
charge to the target group, and in Senegal the voucher is worth a discount of around
US$1.50 from the cost of an ITN.
2.2 Integration of ITNs with expanded routine child health services
2.2.1 Child Health Week / Child Health Days
Although static and outreach facilities have potential for reaching children under1 year
with EPI, and therefore with other child survival interventions, the potential is much
reduced for children aged 12 months to 5 years. Child Health Week (CHW) is an
intensified delivery and promotion of child health interventions through routine services.
Where outreach services are generally provided on a monthly schedule thereby reaching
each outreach area at intermittent intervals, all areas are covered during CHW. CHW is
used as a one-stop opportunity to provide intensified delivery of a minimum package of
services together with health education on preventive care to children aged 0 to 59
months. The goal of CHW is both to increase coverage with child survival interventions
and to encourage increased use of routine services for these interventions by creating
awareness and demand.
Child Health Weeks and Child Health Days are not campaigns; they are “expanded routine”. They generally involve variable packages of child survival interventions such as EPI vaccines, vitamin A supplementation, growth monitoring, and ITN (re)treatment (delivery of ITNs has been less frequent-see below). Other services have included education of caregivers on home management of fevers, promotion of use of iodated salts, awareness creation on HIV/AIDS and promotion of male and female condoms, family planning services, distribution of iron tablets, distribution of de-worming tablets and birth registration. A major difference between CHW and campaigns is that during campaigns children of the target age are immunized regardless of their immunization status, whereas during CHW immunizations are conducted according to health cards. Scheduling of CHWs/CHDs varies; in Ghana CHW is conducted once a year, whereas in Uganda and Zambia it is twice yearly. In Kenya although there is currently no CHW, CHDs are spearheaded by UNICEF at the sub-national level and implemented intermittently. To date CHWs have been used more for the delivery of (re)treatment than of ITNs, although ITNs have been delivered in some districts in both Ghana and Zambia. In Ghana in particular the way in which CHW has been implemented, and to an extent the interventions that have been delivered, have varied considerably between districts. Services have predominantly been delivered free of charge through CHW. 2.2.2 Enhanced outreach
Outreach is used to cover areas where access to fixed facilities is low. Enhanced
outreach involves broadening the package of interventions available through outreach.
In Ethiopia, access to fixed health facilities is low. The MoH is planning to establish a
cadre of trained health workers to provide expanded coverage with child survival
interventions through the Health Extension Package (HEP). The HEP includes outreach
services such as immunization, Vitamin A supplementation, oral rehydration treatment
(ORT), family planning and focused Antenatal Care. UNICEF is supporting the
distribution of LLINs through this Expanded Outreach Strategy (EOS).

2.3 Integration of ITNs with vaccination campaigns
2.3.1 Measles SIAs
Integration of ITN delivery with measles campaigns has been carried out in four
countries to date. The first was in Lawra district in the Upper West region of Ghana in
2002; the second in five districts of Zambia in 2003; the third was a nationwide
integrated child health campaign in Togo in 2004; and the fourth in Lindi region of
Tanzania in 20053. The campaigns have been conducted over a period of three to seven
days. In Ghana and the United Republic of Tanzania, measles campaigns fixed and
mobile sites were used as delivery points for ITNs. In Ghana, ITNs were also taken to
the homes with eligible children who were known not to have attended the campaign. A
similar system was used in four out of the five Zambian districts, whilst in the fifth,
Kalulushi District, a discount voucher was given with immunization, which could be
exchanged for an ITN at nearby retail outlets. During the national distribution linked to
3 At the last minute, the Red Cross also distributed ITNs in three additional districts (Tanga Urban, Pangani, Rufigi) during the same campaign. the measles SIA in Togo, delivery points included 480 clinics and 149 mobile teams. Both polio and measles vaccinations were given alongside LLINs and mebendazole. All ITNs delivered in the integrated measles campaigns have been free of charge to the target group. 2.3.2 Polio national immunization days
There has been less focus on the delivery of ITN through NIDs than through measles
campaigns. With only six countries continuing to have endemic transmission of
indigenous wild poliovirus, the goal of eradication is fast approaching, and NIDs are
therefore a time-limited intervention. The number of countries in which NIDs are
conducted, and their frequency within countries, will decrease. Integrated delivery of
ITNs with NIDs was carried out in Central Region, Ghana, in October 2004. The
campaign was conducted in all districts of the region. Caretakers of children under five
were given a coupon which could be exchanged for an ITN with a top-up fee of 20,000
cedis (approximately US$ 2.40). Health staff sell the ITNs at fixed sites and some are
now taking ITNs with them on outreach visits so that coupon sales can be made.
There are also plans for distributing ITNs during the second round of polio NIDs in Niger
in December 2005.
2.3.3 Tetanus toxoid SIAs
There is a current push to eliminate neonatal tetanus through the use of TT SIAs. The
aim of the SIA is to vaccinate at least 90% of women of childbearing age with three
properly spaced doses of TT in high-risk areas/districts where women have not been
sufficiently reached by routine immunization activities. The need for multiple doses has
operational implications if consideration is being given to integrating with other
campaigns such as measles. There are no reports of any TT SIAs which have been
integrated with ITN distribution.
2.3.4 Yellow fever
As with TT campaigns above, there are no reports of any examples of integrated
delivery of ITNs with a yellow fever campaign.

3. Outputs and outcomes of integrated delivery models
When ITNs are delivered through health facilities to target groups, it is assumed that
they will be used by these target groups, rather than sold on or used preferentially by
other members of the household. Where they are not used by target groups or are sold
on, output data (ITNs delivered to the target group) will not produce expected outcomes
(use by the target groups). A comparative assessment of the outputs and outcomes of
these different delivery systems on coverage of target groups with ITNs is not possible
as the scale of implementation has varied, and evaluations have been infrequent.
Therefore data from specific examples where data are available are presented.
ITN coverage encompasses indicators for both household ownership and use amongst
target groups, and these indicators are not used consistently amongst the programmes
reviewed. The recommended indicator for assessing use amongst target groups is “the
proportion of the target group (pregnant women/children under five) who slept under a
ITN the night preceding the survey”. There is also lack of clarity on the definition of an
ITN among different programmes. An ITN may be a net that was “ever treated” with
insecticide or one that is considered as “currently treated”. Currently treated may be
defined as treated within the last six (or 12) months, a pre-treated net bought within the
last six (or 12) months, or an LLIN.
3.1 Routine systems
3.1.1 ANC/MCH
Data on the total number of ITNs delivered through these systems across SSA is not
available. However, the average number of monthly sales in 10 countries where delivery
is supported by PSI is 411,500, ranging from 4500 in Rwanda to 150,000 in Kenya. The
ANC model of delivery of ITNs in Malawi went to national level between June and
December 2002. Between March and December 2004, 1 million ITNs were sold to
pregnant women and children under five through ANC in Malawi. A national level
household survey was conducted in February 2004 (8) which provides evidence on the
outcome of the programme (see Box below).


A household survey undertaken in Malawi in 2004 found that 31.4% of pregnant women and 35.5% of children under five slept under an ITN the night preceding the survey. This coverage varied widely between districts, with four out of the twenty-eight districts in the country having reached the Abuja target coverage of 60% of pregnant women and children under five sleeping under an ITN the night before the survey. The proportion of target groups sleeping under an ITN was higher in urban than in rural areas: pregnant women, 49.1% urban and 29.0% rural; and children under five, 50.1% urban and 32.2% rural. Household ownership (proportion of households with at least one ITN) was also higher amongst the wealthier socioeconomic groups: 87.8% in the “wealthier”, 59.7% in the “moderately poor” and 31.1% in the “poorest”. Coverage in target groups by socioeconomic status was not presented. The study estimated that 9.8% of the health facility ITNs had leaked into local The household survey presented in the box above did not include indicators on coverage of childhood vaccinations, so it is not possible to assess the impact of integrated delivery of ITNs and immunization. In voucher schemes outputs are measured by the voucher redemption rate. The rate is calculated using two sets of data: the number of vouchers distributed to the target group and the number of these vouchers that are redeemed by the retailer in exchange for cash or more stock. The redemption rate is then calculated as the proportion of vouchers issued to pregnant women that are redeemed. Redemption rates for voucher schemes in Zambia are presented below: In the one year pilot from September 2002 to October 2003 in two districts of Zambia 12,707 vouchers were redeemed, which represented a redemption rate of 74%. The voucher had a value of US$ 2. During the roll-out phase of this scheme in 10 districts the voucher value increased to approximately US$ 3.30. Between October 2003 and October 2004 40,037 vouchers were redeemed. This represented a redemption rate of 66.2%. During a measles campaign in June 2003 in one district of Zambia, 14,792 vouchers were distributed. These vouchers provided 100% subsidy on ITNs and the redemption rate was 99.3%. Coverage data from the two large-scale voucher schemes in Ghana and the United Republic of Tanzania is not yet available; data from the two pilot districts in Tanzania show variable achievement between the two districts, with coverage generally higher in Kibaha district as compared with Kilosa. Coverage (proportion of the target groups who slept under an ITN the night before the survey) in Kibaha achieved 50% for pregnant women, 27.9% for children under five, and 43.6% for children less than one year (9). The equity ratio was 0.33 for pregnant women and 0.11 for children under five. This compares the proportion of children covered from the lowest socioeconomic groups with the proportion covered in the least poor. An equity ratio of 1 indicates equal coverage in the poorest and least poor, pro-rich bias increases from 1.0 to 0 and pro-poor coverage is indicated with rising values above 1. 3.1.2 Intervention Packages
In the four UNICEF ACSD HIP countries baseline coverage (proportion of children under
five sleeping under an ITN the night before the survey) in 2001 was compared with mid-
term coverage in 2003 (10). The surveys included both specific household surveys
carried out to evaluate the impact on coverage of the ACSD programme, and
Demographic and Health Surveys (DHS). The ACSD districts are compared with control
districts (neighbouring districts where the ACSD programme was not implemented). It is
possible therefore to compare the change in coverage in the ACSD districts with that in
neighbouring districts without the intervention. Increased coverage was seen in all four
countries (Table 3), with both Mali and Senegal exceeding the Abuja targets for
coverage in children under five within intervention districts.
Table 3. Coverage of children under five with ITNs at baseline and mid-term
Coverage
Baseline 2001
Mid-term 2003
of under-
Control (%)
Control (%)
fives with
ITNs
Benin 5.3a
Note, coverage is defined as the proportion of children under five who slept under an ITN the night before the survey. a DHS surveys Coverage of pregnant women was lower than that of children under five in three of the four countries, the exception being Ghana (Table 4). Coverage reached the Abuja targets in Mali only. Table 4. Coverage of pregnant women with ITNs at baseline and mid-term
Coverage
Baseline 2001
Mid-term 2003
of pregnant
Control (%)
Control (%)
women with
ITNs
Benin 0

Where DHS surveys are used the outcomes of the intervention may be underestimated
because the ACSD is district-based and may not cover all districts within a
region/province. The DHS present data at the national and at regional/provincial level,
while district-based data are not available. The only HIP country where DHS data are
used in 2003 was Ghana, where the 21% coverage represents DHS data for Upper East
Region. ACSD is operational in all districts of this region and therefore the data are
representative.
Does integrated delivery of ITNs with ANC increase ANC attendance?
It is possible that delivery of ITNs through ANC will have a positive effect on attendance
rates at ANC, on the timing of first ANC visit, and on the coverage of TT. Evidence from
ACSD districts in Senegal and Mali provides some support to the hypothesis that
delivery of ITNs increases attendance at ANC. However, these data are not adjusted for
any of the many confounding factors that may influence these outcomes.
In ACSD districts in Mali, the proportion of pregnant women attending ANC ≥3 times per pregnancy increased from 24.9% in 2001 to 54.2% in 2003. This was 30.7% (p<0.01) greater than the increase in control districts during the same period (those without ACSD distribution of ITNs). ITN coverage amongst currently pregnant women increased from 5% to 67.7% in ACSD districts during the same time period and from <1% to 7% in control districts.
Does integrated delivery of ITNs with ANC increase TT coverage amongst
pregnant women?
A minimum of two doses of tetanus toxoid are required for protection against neonatal
tetanus. Data on coverage with TT2 as compared with ITN coverage in pregnant women
are subject to the same problems as that of ANC coverage, which is that a range of
confounding factors may have a significant influence on the outcomes. Evidence from
the ACSD programme in Mali, however, generally supports an increase in TT2 coverage
with that of ITN coverage.
In ACSD districts in Mali coverage with TT2 increased from 22.2% in 2001 to 58.8% in 2003, in control districts coverage increased from 20.3% in 2001 to 38.9% in 2003. This represents an 18% (P=0.05) greater increase in ACSD Assessment of the proportion of pregnant women adequately covered with sufficient doses of TT using routine data is problematic. Firstly, many women lose their ANC cards and/or cannot recall whether they have been vaccinated. They may therefore be given
several “first” doses. Secondly, women who have received a full schedule of
vaccinations during a previous pregnancy will not be revaccinated. In Upper East Region
of Ghana, whilst ANC attendance has risen, TT vaccination routine data showed a
decrease. These problems mean that it is difficult to evaluate the impact of delivery of
ITNs through ANC on TT coverage data.

3.2 Expanded routine
Child Health Weeks and Child Health Days are a relatively new delivery mechanism for
child survival interventions, and countries where they are currently implemented are still
developing their systems for planning, implementation and monitoring. During the
December 2003 CHW in Zambia 69,389 ITNs were (re)treated. This represents data
from thirty-five out of the fifty-nine districts that reported on CHW activities, the remaining
fourteen not reporting on ITN (re)treatment. Using distribution data from the National
Malaria Control Centre (NMCC) this represents 22% (69,389/308,856) of the nets in the
thirty-five districts. Administrative data on numbers of ITNs are, however, prone to
problems (section 5.2.6).
3.3 Campaigns
Numbers of ITNs distributed during the four experiences of integrated delivery of ITNs
and immunization through measles campaigns, and the outcomes, are presented in
Table 5. In Ghana where implementation involved one district only, the Abuja targets
were met (see note below on indicators), in Togo and Zambia where implementation
was on a larger scale, coverage through the campaign was approximately two thirds of
that required to meet the Abuja targets for children under five. In Zambia coverage due
to campaign plus other delivery systems increased coverage to the target levels of 60%.
Results from the United Republic of Tanzania are not yet available.
The coverage indicators used in the integrated distribution of ITNs with measles
campaigns in Ghana and Zambia vary from the standard RBM-recommended indicators.
The indicator used in these campaigns is “the proportion of households where the index
child slept under an ITN the night before the survey”. The denominator is therefore
based upon the number of households, whereas the standard RBM indicator uses a
denominator of the number of children under five surveyed. The index child is defined as
the youngest child who usually sleeps in the household who was at least six months old
at the time of the campaign. During the Togo campaign standard indicators were used to
evaluate the outcomes of the distribution.
Table 5. Outputs and outcomes of ITN delivery integrated with measles campaigns
Country Scale
Number of ITNs
population distributed
campaign
campaign
(children
coverage
coverage with
under-five
with any ITN
campaign ITN
Ghana and Zambia = “proportion of households where the index child slept under an ITN the night before the survey” Togo = “proportion of children under five who slept under an ITN the night before the survey” The disparity in coverage of ITNs amongst children of differing socioeconomic groups in each campaign was assessed by the equity ratio (Table 6). Table 6. Equity across socioeconomic groups of coverage of ITNs delivered
through integrated measles campaigns
Country
Equity ratio
Pre-campaign ITN*
Post campaign ITN
Post
campaign
any net
Urban Rural Total Urban Rural Total
a household ownership (all households) In Ghana pre-campaign coverage was assessed using exit interviews. The sample is therefore subject to bias which makes it not directly comparable to the representative sampling used in the post-campaign survey. In Zambia, pre-campaign ITN ownership was assessed by questioning care-takers one month post-campaign. As mentioned above coverage data from Ghana and Zambia use non-standard indicators, which means that the data on equity ratio are also not directly comparable with that from other studies. In Togo, the equity ratio was reported using household ownership, not use by children under five. During the integrated delivery of ITNs with polio NIDs in central region Ghana (October, 2004), coupons redeemable against an ITN with the addition of a 20,000 cedis top-up were delivered to 297,133 children. This compared to 554,582 children immunized. Monitoring data were used to estimate outcomes as 58.4% of children given a coupon, and 110% immunized. Findings from an evaluation are awaited. Outcome data are summarized in Table 7, and overall findings include: ¾ data on outputs and outcomes from routine delivery systems are less readily available than that from the integrated measles campaigns; ¾ more ITNs have been delivered to date through routine integrated systems than ¾ high levels of coverage (reaching the Abuja targets) have been achieved at district level, by routine and by campaign models; ¾ high levels of coverage (reaching the Abuja targets) have not been achieved at the national level by any single model of integrated delivery of ITNs with immunization; ¾ current data show that integrated delivery of ITNs through measles campaigns is achieving more equitable coverage than integrated delivery through routine systems; ¾ the earlier measles campaigns did not use the RBM standard indicators for ITN coverage, making comparison with other delivery models impossible. Table 7. Summary of coverage outcomes of integrated delivery models across countries
Country
% coverage of
Coverage of pregnant
Equity ratio of coverage
under-fives with
women with ITNs
(district range)
[non-standard
(district range)
[non-standard
indicators]
[non-standard
indicators]
indicators]
Note, these are coverage data from household surveys in areas where the specified interventions were implemented, they do not necessarily represent direct outcomes of the specified intervention alone b “proportion of households where the index child slept under an ITN the night before the survey” where index child is the youngest child in the household who was above six months of age at the time of the survey c “proportion of households with at least 1 ITN” not based on use 4. Considerations in selecting strategies for integration

4.1 Target groups
The target groups for malaria control in most countries of SSA are those who are most
vulnerable to severe outcomes of malaria, which are children under five and pregnant
women. In areas of low endemicity typical of Asia and some areas (particularly highland)
of SSA, all age groups are at risk of severe outcomes and target groups for malaria
control may be selected based on geographical risk. Although in most of Africa the
socioeconomically vulnerable are not often specifically targeted, this is usually because
of the difficulty of finding effective ways in which to do so. The presentation of coverage
of target groups amongst socioeconomic quintiles with the specific purpose of
demonstrating that the poorest have been reached is becoming more common due to
the globally driven poverty agenda.
Target groups for immunization services are more varied depending upon whether these
are delivered through routine services or campaigns, as described above, and also upon
the delivery point (Table 8).

Table 8. Comparison of target groups for malaria control and immunization
services
Intervention Main
Children under-five and women of childbearing age All population EXCEPT children <9 months and
It is clear from Table 8 that the malaria target groups (pregnant women and children
under five) are not represented by any single immunization delivery system, and
therefore a combination of immunization systems is needed for ITN delivery in order to
reach malaria target groups. As discussed previously, it may be possible to reach
beyond the main target group through some of these systems (section 2.1). It is
important to identify those excluded through each system in order to ensure that the
target groups are covered through complementary systems. For example, if ITNs are
delivered through both ANC and MCH it is possible to reach the entire ITN target group.
Where ITNs are delivered through measles SIAs and ANC, children <9 months are
excluded. A proportion of children under one year of age may however be reached if
they sleep with their mother who has received an ITN through ANC.

Are “non-targeted” target groups covered?
Intra-household patterns of use of ITNs may result in those amongst the priority target
group for ITNs but not specifically targeted by the delivery system being a beneficiary of
the intervention. It is likely that in some instances ITNs targeted at pregnant women are
used to cover children under five and vice versa. This is likely to be influenced by a
range of factors and national level evidence is needed. It would be useful to assess the
proportion of “non-targeted” target groups who benefited from the intervention when
evaluations are undertaken, as in the voucher tracking study in Kilosa and Kibaha districts in the United Republic of Tanzania (11). Co-use of ITNs by target groups: Findings from a voucher tracking study carried out for the Tanzania pilot voucher scheme found that 91.2% and 95% (Kilosa and Kibaha districts, respectively) of the women who purchased an ITN with a voucher slept under the ITN whilst pregnant. In these households 29.5% and 13.5% of children under five and 51.3% and 47.3% of children under one were

One ITN per child or one ITN per caretaker?
Where ITNs are delivered through routine services the target is the individual pregnant
woman or child (although policy and practice may differ — see box below). During ITN
delivery integrated with immunization campaigns the policy may be to target caretakers
of children under five with an ITN rather than the individual child. That is one ITN per
caretaker, rather than one ITN per child. In the Tanzanian and Zambian campaigns, the
target was one ITN per child under five, which resulted in many households receiving
several ITNs.
In Kenya, ITNs are targeted to pregnant women and children under five through ANC and CHC. Although the policy is one ITN per pregnant woman and child under five, some nurses are imposing their own criteria and limiting the ITNs to a maximum of two per household. In the 2002 integrated measles campaign in Ghana ITNs were targeted at one per caretaker of children under five, in the Zambian 2003 and Tanzanian 2005 campaigns the target was one per child under five. In the national integrated distribution in Togo 2004 there was confusion on the target group, resulting in some delivery sites giving one ITN per child and others giving one per caretaker. The health workers in less accessible areas were more likely to give one per caretaker as they were worried about running out of ITNs.
A policy decision should be taken early in planning and consensus assured amongst
partners. Factors such as average household size, the size of and number of rooms
within houses, and knowledge of intra-household sleeping patterns are likely to provide
an evidence base for such a policy decision. Where the target group is one per child, an
option is to place a limit on the number per household, with the maximum number
determined depending upon the local context. Experience during the last few years with
targeting of subsidies has shown that health workers frequently impose their own criteria
despite policy guidelines. Such health staff-imposed systems of work are usually due to
shortage of supplies or perceptions of shortage of supply due to delays in replenishment.
Careful monitoring is needed to determine actual practices, and their reasons, so that
remedies can be found.

Can children 0–8 months be targeted with ITNs during measles SIAs?
Measles campaigns target children 9–59 months or 9 months to 15 years depending on
the burden of disease. Consequently children 0–8 months are excluded from receiving
an ITN. Decisions on who is targeted in integrated campaigns are a balance between
intervention coverage amongst priority groups, logistical realities and practical problems
such as the training of volunteers. In Kenya the measles campaign planned for 2006 will
include delivery of ITNs in forty-two districts and OPV in 14 districts. OPV has a target
group of 0–59 months. Delivery of ITNs to children 0–59 months is planned in the
districts with integrated OPV delivery and to 9–59 months where OPV is not included.
4.2 Current coverage of ITNs and delivery systems for ITNs
Coverage of ITNs is measured through household surveys. Within the context of scaling
up coverage to the national level, nationally representative household surveys are
needed. Demographic and Health Surveys (DHS)4 and the UNICEF Multiple Indicator
Cluster surveys (MICs)5 are the main source of such data in terms of the monitoring of
national progress towards global targets. However, they are undertaken infrequently,
approximately every five years as discussed above.
In most countries of Africa, there is still inadequate access to a supply of ITNs for target
groups. Insufficient funding means that, where the commodities are available, choices
have been made on where in the country they would be targeted. Consequently,
although there is a wide consensus on targeting of the biologically vulnerable, with the
exception of the integrated measles campaign in Togo, efforts have in practice been
targeted within defined geographical areas. In Malawi, integrated delivery of ITNs
through ANC has recently gone to national scale; this was achieved through expansion
of a small-scale pilot programme with the availability of increased funding. Geographic
targeting of ITNs within endemic areas has been a consequence of insufficient funding
(with the exception of pilot projects and disaster response) and therefore scale of
deployment. There have been a range of criteria upon which these selections have been
made, and these have frequently been based upon poverty levels and health indicators.
In order to ensure that ITNs are available to target groups throughout the country it is
useful to conduct a district-by-district analysis of ITN delivery systems and the target
group reached by each of these systems. Once this analysis has been carried out, then
access by target groups at sub-district level may be assessed and need for any
additional strategies to focus on the “hard-to-reach” determined. In this way geographical
inequities may be addressed.


In Ghana twenty districts (two from each of Ghana’s ten regions) were designated “RBM focus districts” and ITNs donated to the national malaria control programme by partners distributed within these districts. Ghana UNICEF selected countries for their ACSD programmes in West and Central Africa based on high under-five mortality rates (U5MR). In Ghana, the selection of regions in which the UNICEF ACSD package was to be implemented was based on those with the highest levels of poverty. Within these regions selection of districts seems to have been more historically based. Central Region was selected for integrated ITN and polio delivery 4 ORC Macro Demographic and Health Surveys (DHS). ORC Macro, Calverton, MD. www.measuredhs.com 5 UNICEF Monitoring the Situation of Women and Children www.childinfo.org
4.3 Current coverage of EPI
Although EPI is undeniably a public health success story, with more than 70% of the
world's targeted population being reached with immunization6, coverage has stagnated
or decreased in some countries over the last decade, mostly in the poorest countries of
Africa. This is due to the weakening (and in some cases collapse) of the health services.
Coverage is particularly low in some countries of West Africa, and more worrying is the
disparity in coverage levels within countries. For example, in Niger coverage of all six
EPI antigens in children one year of age varies between 9.9% and 76.2% in the different
provinces of the country. Disparity in Ghana is less acute than in Niger, ranging from
48% in northern region to 82.3% in Volta Region, but is still highly inequitable. This will
limit the reach of ITNs delivered through the same system unless ITNs become valued
by the population to the extent where ITN delivery increases coverage levels of EPI
(section 3.1).

5. Issues in planning, implementation, monitoring and evaluation

Many of the opportunities and challenges presented by integrated delivery of ITNs and
immunization cross-cut the various delivery models, and some are specific. Cross-
strategy issues in planning and implementation are presented in section 5.2. Although
the issues and experiences presented are by no means exhaustive, they outline some
important considerations when planning and implementing integrated delivery of ITNs
and immunization through the various models.
5.1 Opportunities and challenges of specific models
Opportunities and challenges of specific models are summarized in Table 9.
5.1.1 Routine delivery
Maintaining a constant supply of ITNs has been a major problem in all integrated routine
delivery systems. Factors contributing to this include problems in planning, forecasting,
and monitoring but also in insufficient and poor continuity of funding. Evidence of the
effect of stock-outs of ITNs on the delivery of interventions with which it is integrated,
(such as EPI) has not been documented. However, there is anecdotal evidence from
Kenya that attendance at both ANC and MCH is increased at facilities where ITNs are
available and decreased at those where they are not. ITNs are not available in all health
facilities in malaria risk areas in Kenya. Supplies of ITNs are dependent upon the health
facility purchasing an initial seed stock of ITNs. Where facilities have done so, they
report that people are travelling further to attend these facilities rather than attending
those that are closer, but without subsidized ITNs. The ANC delivery model for ITNs is
relatively new in Kenya but it should be possible after a longer period of implementation
to use routine data on ITNs and attendance figures to assess the impact of availability of
subsidized ITNs on attendance for ANC and EPI.
There are many examples of health staff devising their own policies and imposing their
own eligibility criteria for ITNs. Experience from the voucher scheme in Volta Region,
Ghana, shows that enhanced training can effectively deal with some of these problems.
The important issue is to ensure that regular monitoring is in place to identify and
respond to problems.
6 See GIVS pages 4 and 5 for the latest coverage summaries www.who.int/vaccines/givs In the Volta Region pilot voucher scheme, Ghana, 50% of health facility staff interviewed three months post-implementation had decided at least once not to give a voucher to a pregnant woman because she was “not ready with money”. This was addressed by retraining and increased supervision and was not identified as a problem in the monitoring surveys six months later. Current experience is that financing strategies may vary within different areas of a country and also over time within the same area. In Ghana the pricing strategy of the ACSD programme does not follow that of the national programme. The national programme delivers ITNs in at least two districts per region across all ten regions of the country. These ITNs are sold from ANC clinics to pregnant women for 20,000 cedis. There are joint ACSD and National Malaria Control Programme (NMCP) districts, where these are clearly non-complementary strategies. The NMCP ITNs are sold by ANC staff from the health facilities, whereas the policy of the ACSD programme (and of the two regions in which they are implemented) is that health facility staff provide ITNs for free. Competing pricing policies have the capacity to impact not only on the uptake and use of ITNs, but also, where integrated with the delivery of other health interventions, on the uptake of other interventions. In addition, differing financing models and incentive schemes may also impact upon the motivation of health staff in delivering them. In Kenya, ITNs are sold to health facilities for approximately US$ 0.40, they are then sold by health staff to pregnant women and children under five for US$ 0.66. The health facility uses US$ 0.40 to restock and then is able to accumulate the remaining US$ 0.26 from each ITN sold to increase their stock levels or for general needs within the facility. Uses have included transport of vaccines for CHCs in those facilities with no refrigeration facilities, and for transport of emergency referral patients. There are suggestions that Kenya will move towards a policy of free ITNs for all target groups and, under the current circumstances, a change in strategy to delivery of free ITNs to the target group is likely to create problems in terms of health staff motivation.
Difficulties in implementation of voucher schemes have been encountered in health
facilities where ANC staff have previously sold ITNs (12) This is mainly due to the fact
that selling ITNs has included an incentive for the midwife, whereas the current practice
of delivering vouchers does not.
Direct product or voucher?
As both direct product and voucher systems for delivering ITNs on a large scale are
relatively new, there are still many questions to be answered. However, the basic
assumption in selecting between the strategies is:
¾ Direct product delivery through ANC is most appropriate where ITN commercial sector supply and distribution is underdeveloped. ¾ Voucher system delivery is most appropriate where there is an active (or the likely potential for an active) commercial sector for ITNs. The advantages of voucher systems over those of direct product distribution through health facilities are that: 1) there is less of a burden on health staff, particularly in comparison to where health staff sell ITNs; 2) the retail sector is not “crowded-out” by direct public sector distribution; 3) the retail sector is “crowded-in” resulting in greater accessibility of ITNs for non-target groups. Disadvantages may include: 1) supply may not have the capacity to meet demand; 2) supply relies on the pull created by demand; 3) changes in markets and currency fluctuations may result in increased or decreased value of the voucher; 4) redemption systems need managing; 5) there is potential for fraud. Also, the effort required to design and implement a national voucher scheme should not be underestimated. Table 9. Opportunities and challenges of models of integrated delivery of ITNs and
immunization
Model Category
Opportunities
Challenges

- reaching the geographically and economically - provides a constant source for target - maintaining constant supply of ITNs group (depending upon constant - collaboration between Malaria, and Reproductive Health Departments - health staff imposing their own eligibility criteria - consolidating financing systems - reaching the geographically and economically - provides a constant source for target disadvantaged group (depending upon constant - collaboration between Malaria, EPI, IMCI and Child Health Departments - increasing EPI coverage - building an integrated sustainable system - capitalizing on contact opportunities - provides a constant source for target group (depending upon constant supply) - monitoring and evaluation of the impact - maintaining constant supply of ITNs and vaccines - monitoring and supervision of activities - reaching children born in the 3 to 5 years - balance of timing of the campaign to optimize both malaria and immunization outcomes - target group confusion where multiple interventions are delivered - insufficient training of volunteers - collaboration between EPI and malaria - timely supply and distribution of ITNs - transportation of ITNs by volunteers conducting Where vouchers have been used to deliver ITN subsidies during campaigns they provide a means of logistical ease for delivery of subsidy compared to the ITNs themselves, which are bulky and heavy. Where vouchers are exchanged for an ITN at a health facility, the positive impact on the commercial sector, one of the objectives behind the design of voucher schemes, is lost. 5.1.2 Expanded routine
In most of the countries where CHWs are currently implemented they are a relatively
new delivery model, such that systems are still being developed and lessons being
learned. They generally attempt to enhance the delivery of interventions, health
messages and social mobilization over a short period of time in a similar fashion to that
of campaigns. However, in both Ghana and Zambia the extra funding available during
the initial CHWs has now stopped and districts need to fund the activities through their
district budgets. This has implications for the level of human resources that can be
mobilized to increase the concentrated delivery required. Countries are attempting to
effectively institutionalize and sustain CHWs within their current budgets, and are
therefore striving for a sustained system.
Monitoring systems have been developed in Zambia, including the use of tally sheets
similar to those for EPI. Outputs for each of the interventions are recorded on the tally
sheets. This is equivalent to the number of nets (re)treated or the number of treatment
kits distributed. During CHW in Ghana, some facilities treat nets with insecticide and
others distribute treatment kits. In both Ghana and Zambia some health facilities have
distributed ITNs during CHW and the decisions have been made at district level.
5.1.3 Campaigns
Even in countries where malaria is endemic there may be considerable seasonality in
transmission and levels of transmission based upon local climate conditions such that
malaria transmission may vary substantially from year to year. Malaria control activities
can also substantially alter the transmission season. Increased transmission is usually
closely linked to the rainy season. The use of mosquito nets is largely driven by
mosquito abundance and biting intensity, so that ITN use is generally linked to the rainy
season when mosquitoes breed.
Although both polio and measles can occur throughout the year, they each have high
and low transmission seasons. In tropical climates the high transmission season for polio
is usually during the rainy season, and, in temperate climates, during summer and early
autumn. In tropical climates, measles transmission increases after the rainy season.
Both polio and measles campaigns are usually conducted during low transmission
seasons, that is, during the dry season when roads are accessible. The optimum time for
delivery of ITNs is just before the rainy season.
In countries where measles transmission is relatively low, as is becoming the case in a
growing number of countries, it should be possible to be able to interrupt transmission
during the ‘high season’. Therefore considerations for timing of the campaign would be
dominated by logistical considerations balanced by the optimum time for delivery of
ITNs. Under these circumstances the risk would then be the negative impact of the
advent of cases after the campaign because the virus had already been incubating.
As polio NIDs in Ghana involve house-to-house visits and ITNs are both bulky and
heavy, a coupon was given with immunization rather than a direct product. The coupon
entitled the recipient to an ITN for 20,000 cedis (approximately US$ 2.40) at health
facilities and other ITN depots. One coupon was given per caretaker of children under
five. Efforts were made to ensure that hard-to-reach communities were able to access
ITNs with their coupons. Where caretakers reported that they had lost their coupons,
they were told that they could buy an ITN for 20,000 cedis anyway. The coupons were
therefore not valued in the same way that they are in the Volta Region voucher scheme.
The vouchers represent actual money, and they provide a discount. There were reports
that some of the volunteers were asking caretakers if they could pay the 20,000 cedis
before giving them a coupon, that is as in Volta Region, where they ‘ready with money’.
The volunteers not only move from house to house during polio NIDs, but also more
generally within the community, taking any opportunity possible to immunize a child.
Some children are immunized whilst unaccompanied by an adult (schools, marketplace),
so these children were not supplied with coupons as the policy was that coupons be
given to caretakers.
5.2 Cross-strategy issues in planning, implementation, monitoring and evaluation
5.2.1 Forecasting and procurement
Obtaining and maintaining an adequate supply of ITNs has been a problem for most if
not all integrated programmes and delivery systems, both routine and campaign, and
through both the public and private sector. This has been amplified with the introduction
of, and preference for, long-lasting insecticidal nets (LLINs). UNICEF Ghana intended to
deliver LLINs through the ACSD programme and MoH through the Central Region polio
NIDs, but switched to pre-treated and bundled nets due to a global shortage in LLIN
supply. Procurement of ITNs requires a lead time of several months up to one year, to
allow shipment and customs clearance. Supply, particularly of LLINs, cannot be assured
on a short time scale. This is in part due to increased global demand but also to the
often complex importation procedures. Some manufacturers supply regular lead time
information to their distributors and other partners. For routine systems where funding is
assured over a period of time, forecasting and regular standing orders with
manufacturers can help to reduce stock-out problems. Bulk institutional orders such as
those from countries receiving Global Fund for AIDS, Tuberculosis and Malaria
(GFATM) funding can cause problems in maintaining availability on the global market. In
the current situation where demand is higher than supply capacity, decisions will be
taken on which country gets the available LLINs and which ones do not.
In Ghana, the pilot ITN voucher scheme in Volta Region experienced stock-outs of
approximately three months due to the large demand for ITNs from a scheme in urban
areas of other regions. This was partly due to much higher demand for ITNs than had
been anticipated, but also to inadequate financial and procurement planning by the
commercial partners.
Supply of ITNs has been a problem during integrated campaigns. This has sometimes
been due to late securing of funding for the ITNs, such as in Zambia, and sometimes
simply due to late planning. Late supply or non-availability of ITNs should not delay the
implementation of immunization campaigns. In Ghana, the ITNs for the integrated
distribution with NIDs arrived after the campaign. The coupon recipients had to wait
approximately two weeks before they could exchange their coupons for an ITN.
Experiences from the integrated measles campaigns in Ghana, Zambia and Togo
suggest that it takes six to eight weeks for the ITNs to get from the manufacturer to the port. In Tanzania, the ITNs were procured from a national supplier by UNICEF. 5.2.2 Planning
All partners need to be involved from the beginning of the planning process; this
facilitates consensus building and determining the most appropriate roles of each
partner organization based on institutional strengths. Strong partnerships at the planning
phase are more likely to facilitate a pooling of resources, both financial and human.
Where programmes involve a large number of partners a co-ordinating committee will
help to facilitate consensus building, but this committee must be linked to a final
decision-making authority in the MoH. A policy decision on targeting of each child under
five with an ITN, or targeting caretakers of children under five, was unclear amongst
those delivering the ITNs in the Togo integrated measles campaign. This caused
confusion to the extent that some volunteers gave an ITN per child and others an ITN
per caretaker, the decision often being dependent upon perceptions of supply levels.
Partnership issues need to extend to include issues in integrating and institutionalizing
new initiatives into routine systems. Initially, the UNICEF ACSD programme in the two
regions of Ghana was perceived by regional and district health staff to be separate from
other routine activities because it was funded separately. Over the last couple of years
the package has been integrated to the extent that it is perceived as a component of the
routine system. CHW was implemented for the first time in Ghana during May 2004.
Planning at the national level involved the managers of several programmes including
EPI, Nutrition, Child Health, and Malaria Control. The planning period at the national
level was sufficient; however, the time remaining before implementation for training at
the regional and district levels was not long enough to allow for adequate advocacy and
institutionalizing of the intervention at these levels. This resulted in different
understanding, interpretation and implementation of the interventions between regions
and between districts. The issue for the second year of CHW is to institutionalize the
programme.
Partnership experiences and lessons learned are discussed in greater detail in section 6.
5.2.3 Effective targeting and tracking
Strategies to deliver ITNs to pregnant women through ANC, as with all targeting
strategies, need to be evaluated for targeting efficiency. Careful tracking in Kenya found
that 20% of 70,000 ITNs distributed to District Health Management Teams (DHMTs) in
thirty-five districts, for delivery to pregnant women through ANC, went to non-target
groups (13). Eighty percent of the leakage (defined as not delivered to pregnant women)
of nets from the system in this study was at the DHMT level, that is, before the ITNs
reached ANC.
Minimising leakage is likely to be significant in ensuring complementarity of alternative
delivery systems, particularly, but not exclusively, where the commercial sector is
involved. The RBM Strategic Framework for Scaling-up ITNs recommended the use of
sustained and targeted subsidies. Untargeted subsidies are not recommended. In
Ghana untargeted subsidies are provided by the agents who sell ITNs door-to-door in
the ACSD districts. The subsidy delivered through the sales agents to the general
population is the same as that reserved for target groups (pregnant women and children
under five) by the MoH. In Zambia, blanket subsidies are delivered by malaria agents
through the Community Based Malaria Prevention and Control Programme (CBMPCP), the level of subsidy being greater than that given to pregnant women through subsidies at ANC. Delivery of highly subsidized ITNs to non-target groups and leakage onto open markets have two negative impacts: 1) they divert resources available for subsidies from the identified vulnerable groups; 2) they undercut commercial market prices and has a negative impact on developing an enabling environment for the development of sustainable private sector distribution systems. The use of sales agents in the ACSD programme has the capacity to increase sales, but, where incentives are included with each ITN sold, they also have the potential to increase the proportion of sales to non-target groups. 5.2.4 Geographical boundaries
As mentioned above, geographic targeting of ITNs can introduce inequities which have a
significant impact on implementation. During integrated ITN and immunization
campaigns, careful forecasting is vital to ensure sufficient supplies of vaccines and ITNs.
In Zambia, attendance at the measles campaign from other non-target districts caused
logistical problems in supplies of vaccines. Cross-national border attendance at the
integrated measles campaign was also seen in Togo from Volta Region, Ghana.
Monitoring of the voucher scheme in Ghana found that some pregnant women returned
their vouchers to midwives as they had already received an ITN from the campaign in
Togo.
The impact of ITN stock-outs due to underestimates of needs or to inflated attendance
from outside of the geographical target area becomes more serious where it negatively
impacts on immunization coverage. At some of the distribution points in Zambia
vaccinations stopped when the stock of ITNs ran out. In Upper East Region of Ghana
some communities (in Bawku West) refused immunizations because they wanted to
receive ITNs with immunization in the same way that their neighbours in Togo had.
These are major issues to take into consideration for Kenya where ITNs will not be
delivered in all districts with the measles campaign in 2006, but just in forty-two malaria
endemic and epidemic districts.
5.2.5 Communication messages
Where target groups vary between interventions there may be problems in combining
messages so that the population are clear on their entitlement. In Zambia the messages
needed to effectively communicate that measles vaccination was for those aged 9
months to 15 years; vitamin A was for under-fives (6–59 months), mebendazole for
those two to five years and ITNs to under-fives. There was ‘civil unrest’ in some of the
campaign sites in Zambia when those attending who were five years and over were not
given an ITN. There were reports that some people started to change the birth date on
their child’s EPI card. Clearly the range of interventions delivered and the consequent
diversity of ages for each intervention creates difficulties in designing effective
communication messages. Perhaps more importantly, this will also impact upon the
amount of training needed for the volunteers who are administering the interventions.
5.2.6 Monitoring and evaluation
Household surveys such as the DHS and the MICs assess national and
regional/provincial coverage; however, they do not incorporate tools to assess coverage
achieved by alternative delivery systems. Where there is more than one delivery system in operation, and where ITNs are also delivered through the private sector, it is difficult to accurately assess the proportion of any coverage recorded that was due to a specific delivery system. It is however possible to do this with the addition of a simple question on “source of the ITN” to survey tools, together with careful tailoring of response categories on the type of ITN acquired. Coverage of interventions in the DHS and MICs surveys is assessed at the national level, but the sampling scheme enables breakdown of coverage data to regional/provincial level. District level comparisons are not possible, which means that where programmes are delivered on a district level scale (such as the UNICEF ACSD programmes in West and Central Africa) it is difficult to measure their impact in terms of coverage through these surveys unless all districts within a province/region are involved. Thus, the impact of the programme will be diluted when assessed at the regional/provincial level. The addition of ITN coverage questions to EPI cluster surveys has been suggested both to enable assessment of coverage at the district level and to increase the pool of surveys providing ITN coverage data. A question on ITNs was added to a national EPI cluster survey in Ghana and a question on mosquito nets on the EPI cluster survey in the Republic of Timor Leste (December 2004) which enabled the collection of data on coverage to district level. It is vital, however, that where such integrated monitoring is undertaken standardized ITN questions (such as those used by the DHS) are used, as experience has highlighted a host of problems and misinterpretations due to lack of standardization of survey tools between countries. Where routine data are used to estimate coverage the denominator is likely to introduce inaccuracies. Population estimates may present problems when calculating vaccination coverage, but on the whole the numerator is less open to inaccuracies. When a child is vaccinated then they have received the vaccine. This is not so when a pregnant woman or a child under five is given an ITN. ITNs are easily transferable and may not necessarily be used regularly even when they are kept. This problem is compounded further when estimating (re)treatment rates. In Ghana UNICEF were disappointed with the (re)treatment rates obtained through the ACSD programme in Upper East Region. On the basis of calculations of the number of ITNs sold through the scheme and the number of (re)treatments undertaken, UNICEF perceived that the programme was not successful. However, data from the 2003 DHS indicates that in this region 24.1% of children under five slept under a net the night before the survey and that 21.0% of children under five slept under an ITN the night before the survey. Therefore 87.1% of the children sleeping under a net in the region were sleeping under ”currently treated” nets. This suggests a very successful (re)treatment service is in operation. The reason for the apparent lack of success of the (re)treatment service when measured through monitoring data is likely to be due to an overestimation of the number of nets in the region. The very high subsidy on ITNs through the ACSD scheme has resulted in an organized system of transfer of ITNs to the open markets in other regions of the country. Most household surveys such as the DHS and MICs are conducted during the dry season, mainly for logistical reasons, as access to remote places is easier. As the use of ITNs is more common during and just after the rainy season, this will result in an under- estimate of use. It is not clear whether this may also affect reported ownership. Table 10. Summary issues and suggested actions in planning and implementation
Subject Issue
Suggested
- Include coverage of “non-targeted” target group within evaluations (e.g. ITN coverage of < 9 months by measles campaigns) season compared with those that do not, in terms of retention rates, use of ITNs, maintenance of insecticidal effectiveness, and the longevity of the net itself. systems already in place Routine systems offer promise of of equity of coverage Pricing policies of different delivery funding - early procurement for campaigns the targeting is only loosely implemented, there is increased capacity for antagonistic interaction with other delivery systems
Subject Issue
Suggested
Health staff impose eligibility criteria absolutely no other eligibility criteria should be imposed the district, regional, or national level diverse target age groups effective communication messages are difficult to design in the community, this may be done in proportion of households where this the absence of a caretaker, where this is the case the caretaker does not receive an ITN
6. Partnerships
6 .1 Key partnerships spearheading integrated campaigns
Partnerships for integrated immunization and malaria programmes in the review
countries have without exception been broad and complex, involving international,
regional, national and sub-national partnerships, including both public and private
sectors, typically involving several government departments, development partners,
funding agencies, NGOs, commercial partners and the community.
6.1.1 Global level
The two main global partnerships behind the integration of immunization and malaria
control are the Roll Back Malaria7 and Measles Partnership.8 WHO and UNICEF are
members of both partnerships and have signed a joint statement formalizing the strategy
for integrated programming for malaria control and immunization. The two organizations
are reviewing experiences to inform the development of a common framework for action
for discussion with national programmes and partners and will request financial and
planning institutions to consider this initiative in health sector planning activities at
country level. The aim is to integrate a holistic package of malaria control interventions
7 RBM founding partners are WHO, UNICEF, World Bank and UNDP 8 The Measles Partnership is composed of the American Red Cross (ARC), CDC, the UN Foundation, WHO and UNICEF in collaboration with IFRC www.measlesinitiative.org with both routine and campaign-style immunization activities. UNICEF is already leading the ACSD initiative in several countries in West Africa, which provides ITNs to infants at the time of routine immunization. The Measles Partnership has spearheaded the integration of ITN delivery with measles campaigns, which have so far been undertaken in Ghana, Zambia, Togo and the United Republic of Tanzania. While both these partnerships are well established — RBM was established in 1998 and the Measles Partnership in 2001 — this is the first time that the two partnerships are working together towards a common goal. The impetus for combining the delivery of ITNs with immunization has come from the commitment to accelerate scale-up of malaria control interventions to reach the Abuja targets. Global partners now urgently need to develop a coherent partnership approach which integrates malaria control (i.e. more broadly than ITNs) with both routine and campaign immunization efforts, based on a rational analysis of risk, target groups and delivery strategies, including mechanisms for partnership support and coordination. 6.1.2 Regional level
These global partnerships are mirrored at the regional level. Both WHO and IFRC have
offices in Harare, and UNICEF has regional offices in Nairobi and Dakar, and all have
provided technical assistance to countries that have undertaken integrated child health
initiatives. To a large extent the technical assistance delivered by each organization has
been complementary rather than a duplication of effort, but as integrated malaria and
immunization initiatives are rolled out across Africa there should be a clear strategy and
plan for technical assistance from all partners to avoid overwhelming countries.
The organization by WHO of the regional workshop to develop a framework for
integrating child survival interventions with immunization activities in Harare, 2–5 May
2005, is a key milestone in formalizing the partnership strategy for this approach. In
addition to the international partners, including WHO, ARC, Canadian RC, IFRC,
GFATM, RBM, CDC, UNICEF and bilateral funding agencies, the workshop also
involved national programme managers for EPI, IMCI and malaria from 8 African
countries. The workshop provided an excellent opportunity to discuss partnership
planning and coordination in the African region. A follow-up workshop on Monitoring and
Evaluation of Integrated Distribution of ITNs with Other Child Survival Interventions was
undertaken in August 2005 in Harare.
6.1.3 Country level
At country level, partnerships have evolved on the basis of a common commitment to
integrated approaches to immunization and malaria control, following the earlier
reasonably successful demonstration projects in Ghana in 2002 and Zambia in 2003. An
increasing number of partners have come forward to lend their support to the integrated
campaigns. For example, there were more than twenty-five different partners involved in
Togo’s National Integrated Child Health Campaign, including six departments of the
Ministry of Health (Public Health, Primary Health Care, Epidemiology, Malaria Family
Health and Health Education), five national Red Cross societies (American, Canadian,
New Zealand, Norwegian and Togo), two UN agencies (UNICEF and WHO), IFRC, GTZ,
four NGOs (Plan Togo, Freedom from Huger, PSI, RAM), CDC, three academic
institutions (LSTM, LSHTM and Geneva University), the commercial sector
(Vestergaard-Frandsen, DHL and Sanofi-Synthelab) and at least four funding agencies
(CIDA, NORAD, GFATM and the UN Foundation (UNF)). This large number of partners

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