Dr Abdul Wasi Asha

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Roll Back Malaria and Cutaneous Leishmaniasis
Control Program for Afghanistan
Inter-country Workshop on Scaling-up ITN
Implementation for Control of Malaria and other
Vector-Borne Diseases in Countries of EMR Abha,
Kingdom of Saudi Arabia 18-20 October, 2003

•  Dr Abdul Wasi Asha
• President, Institute of Malaria and Parasitic
  Diseases
• Ministry of Health, Transitional Islamic
  Government of Afghanistan

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Afghanistan ITNs Strategy(2004-2008)
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Challenges

• Delays in establishing the proposed primary
  health care system. 65 of the population have
  limited or no access to formal health care
• Logistic barriers including limited road access
  to many parts of the country
• Confusion over the integration of a historically
  vertical programme into community-based and
  district health care services
• Bias towards curative care delivery by health
  services and decision makers
• Health services are supported by a multitude of
  partners, creating occasional difficulties for
  coordinated approaches
• Low incentives for government staff forcing
  competent staff to supplement their income
  through private practice or seek employment in
  the private, NGO or UN sectors where income is
  higher
• Limited mobility of women (as health workers,
  household decision makers, and patients)

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Challenges (contd)

• Limited data for planning and monitoring purposes
  (the national Health Information System has not
  operated since 2001)
• Limited knowledge and understanding of malaria
  among some sections of the population (including
  some health workers)
• Low purchasing power among some population groups
  with regard to ITNs
• Absence of private sector participation to expand
  ITN sales
• Ongoing insecurity and political instability in
  some areas.
• Ongoing population and health worker preference
  for indoor residual house spraying and other
  chemical methods of vector control other than
  ITNs for malaria prevention.
• Scale of input (material, financial and
  technical) to achieve coverage is large.

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Afghanistan ITNs Strategy(2004-2008)

• Assumptions
• That security in Afghanistan will steadily
  improve, and that political stability will be
  attained.
• That there will be continued external support to
  Afghanistan over the next 5 years. Support
  includes material, financial and technical and
  comes from a variety of sources including
  bilateral donors, multilateral agencies and
  international NGOs.
• That supply of WHOPES approved LLINs will meet
  the global demand by the end of 2003

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Afghanistan ITNs Strategy(2004-2008)

• VISION
• At least 60 of the target population in
  Afghanistan sleep under insecticide-treated nets
  during the transmission season by the end of
  2008, resulting in reduction of malaria and
  anthroponotic cutaneous leishmaniasis
  transmission.
• In urban areas, the majority of the target
  population will purchase ITNs and home treatment
  kits from the unsubsidized commercial market, and
  vulnerable groups will obtain subsidized ITNs and
  home treatment kits from the public sector and
  NGOs.
• In rural areas ITNs be promoted and distributed
  using community mobilisation strategies, closely
  linked to the implementation of
  community-oriented primary health care system.
  ITNs will be made available to all affected
  members without attempt at full cost recovery,
  and distribution should be highly subsidised or
  free of charge where appropriate.

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Afghanistan ITNs Strategy(2004-2008)

• External support including donor funding will be
  sought to assist in achieving coverage amongst
  vulnerable and rural communities, as well as
  pump-priming the private sector.
• Recognizing the countrys current weak health
  infrastructure, the implementation of this
  strategy at the grass-root level will depend to a
  large extent on the NGOs network through an
  established National Steering Committee (Chaired
  by the MOH) as well as the mobilisation of the
  local community. As the health infrastructure and
  security improves, attempts will also be made to
  strengthen the capability of the public sector
  (MOH) to play a leading role especially in
  providing a conducive environment and in
  addressing issues of equity.

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Afghanistan ITNs Strategy(2004-2008)

• GOAL
• Contribute to the reduction of malaria and
  anthroponotic cutaneous leishmaniasis disease
  burden in Afghanistan
• STRATEGIC OBJECTIVES
• Increased use of ITNs by all household members
  in targeted areas endemic for malaria and
  anthroponotic cutaneous leishmaniasis

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Afghanistan ITNs Strategy(2004-2008)

• PRODUCTS and ACTIVITIES
• Outcome 1 60 of target population will be
  protected by ITNs through adoption and
  implementation of effective strategies by the end
  of 2008
• Mechanisms for identifying target population are
  developed.
• Public/private, private/private partnerships are
  built.
• ITN distribution systems and mechanisms are
  established.
• ITN promotion plan is developed, using
  communication for behavioural impact (COMBI)
  methodology.
• Models and guidelines for targeting subsidies are
  established.
• Procurement strategies are developed.

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Afghanistan ITNs Strategy(2004-2008)

• Outcome 2 80 of nets used by target populations
  are effectively treated with insecticides by the
  end of 2008
• Initial treatment is ensured.
• Accessible and functional treatment / retreatment
  centres are established.
• Treatment and re-treatment promotion plan using
  COMBI methodology is developed.
• Distribution mechanisms/systems for free
  insecticides are developed.
• Distribution mechanisms/systems for individual
  use (treatment kits using social marketing or
  private marketing) are developed.

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Afghanistan ITNs Strategy(2004-2008)

• The Partnership Development Process
• Establishing a National Steering Committee for
  ITN implementation
• Chair MOH
• Members HNI, UNICEF, WHO, PSI, USAID
• Invited members Ministry of Education, Ministry
  of Information, Chamber of commerce, Ministry of
  Finance, Ministry of Agriculture, Provincial MOH
  representative (1).
• Terms of reference
• Identify target population
• Coordinate ITN programming and implementation
• Create strong political support
• Advocate for resource mobilisation and soliciting
  human and financial resources
• Lobby for the removal of tax and tariff barriers
• Coordinating ITN promotion
• Plan mechanisms for targeting subsidies
• Monitor and evaluate implementation for
  continuous improvement
• Set priorities for operational research
• Establish a network of provincial coordinating
  committees
• Develop detailed yearly implementation plans
  specifying targets, indicators, and partners
• Present recommendations and progress reports to
  Country Coordinating Mechanism for GFATM

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Afghanistan ITNs Strategy(2004-2008)

• Establishing or reinvigorating the provincial
  coordination mechanisms
• The National Steering Committee should ensure the
  establishment of the provincial coordination
  mechanisms
• Provincial coordinating mechanisms should build
  on existing coordination mechanisms where
  possible, such as sub-national CCMs of the GFATM,
  health coordination committees, and malaria
  working groups
• Provincial coordinating mechanisms should be
  inclusive of all partners working or potentially
  working in malaria control, including for example
  WV, IMC, Malteser, Merlin, SCA, MSF, Ibn Sina,
  AMI, Mercy corps

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Afghanistan ITNs Strategy(2004-2008)

• Partners
• Alongside the MOH, UN agencies and HNI, a further
  22 partners have been, are, or will be involved
  in implementation of ITNs in Afghanistan
• Swedish Committee of Afghanistan (SCA) Hewad
  QLC ORA MCI ISRA Ibne Sina IAHC Aryan
  Habitat DAC ATA ARCS AMI AHDS TODAI Japan
  World Vision Save the Children US Merlin
  Malteser and Population Services International
  (PSI).

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Afghanistan ITNs Strategy(2004-2008)

• 2. Roles of the partners
• a. Public sector
• Create enabling environment for all partners
• Mobilise resources
• Promote generic demand through use of a variety
  of approaches and channels
• Coordinate and chair the ITN steering committee
  and the involvement of partners in scaling-up
  coverage
• Agenda-setting for operational research, through
  the steering committee
• Set standards and norms for ITNs and
  insecticides, monitor and regulate their quality
• Ensure equitable distribution and access to ITNs
• Coordinate, through the IEC department of the
  MOH, an effective national social mobilisation
  and communications for behavioural change
  programme to ensure correct utilisation and
  monitor usage of ITNs
• With partners, monitor and evaluate efforts to
  scale up effective ITN coverage

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Afghanistan ITNs Strategy(2004-2008)

• b. Private sector
• Create awareness and demand for branded net and
  insecticide products
• Improve product image and acceptability through
  consumer research
• Surveillance and monitoring of the commercial
  market
• Supply, in a sustainable manner, ITNs and
  insecticides for net re-treatment
• Equitable distribution of ITNs, including through
  targeted subsidies for those most vulnerable to
  malaria in accordance with the National Steering
  Committee recommendations
• Execution of social marketing schemes to generate
  demand for generic net and insecticide products
• With partners, monitor and evaluate efforts to
  scale-up effective ITN coverage

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Afghanistan ITNs Strategy(2004-2008)

• c. Non-governmental Organizations (NGOs) and
  civil society
• Equitable distribution of ITNs, including through
  targeted subsidies for those most vulnerable to
  malaria in accordance with the National Steering
  Committee recommendations
• Execution of social marketing schemes to generate
  demand for branded net and insecticide products
• With partners, execute a programme of
  communication for behavioural impact for correct
  usage of ITNs
• With partners, monitor and evaluate efforts to
  scale up effective ITN coverage
• Conduct of operational research in line with
  priorities set by the National Steering Committee

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Afghanistan ITNs Strategy(2004-2008)

• d. Multi-lateral agencies and donors
• Provision of technical support for development of
  guidelines and standards
• Advocacy for prioritisation of ITN programmes for
  the prevention of malaria and other vector-borne
  diseases within the health sector
• Resource mobilisation
• Capacity building of MOH
• Advocate, internationally, for the removal of
  taxes

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Afghanistan ITNs Strategy(2004-2008)

• Operational research.
• To ensure the evidence base of the ITN strategy,
  several areas are identified for operational
  research
• Consumer preference studies.
• Polyethylene Olyset net effectiveness in
  preventing anthroponotic cutaneous leishmaniasis
  (ACL).
• Epidemiological impact evaluation.
• Cost-effectiveness of ITN programme
  implementation.
• Socio-economic burden of malaria..
• Level of ITN coverage needed to achieve public
  health impact.
• Market surveys.
• Update of important vectors of malaria.
• Health worker and household case management

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Afghanistan ITNs Strategy(2004-2008)

• THANK YOU