WHO: delivering insecticide treated nets to control malaria
The next phase of RBM called for the rapid and sustainable scale-up of malaria control measures in Africa, as part of the wider strategic framework for scaling up ITN coverage, and had two priorities:
- To accelerate RBM targets of using substantial public subsidies to guarantee access to ITNs for the most vulnerable.
- To be able to move to a sustainable strategy for maintaining high coverage, even if large-scale subsidies were no longer available.
Malaria is one of the main causes of infant mortality in Africa. It can also result in conditions such as disability, anaemia, low birth weight for babies of infected women, and growth retardation. Insecticide-treated nets (ITNs) can kill and repel mosquitoes, reducing the risk of infection.
Originally, the Roll Back Malaria (RBM) summit, held in Abuja, Nigeria in April 2000, set an ambitious target of reducing malaria by 75 percent by 2015.  In the event the reduction was just 48 percent.  As part of that summit, it set targets for expanding ITN use in Africa — “60 percent of pregnant women and children under five will sleep under ITNs or use other appropriate and affordable means of protection from malaria”.
The public impact
The impact is difficult to quantify, but it was estimated that about 908,000 malaria deaths have been averted through ITN coverage between 2000 and 2010, with three-quarters of the deaths averted since 2006. The reasons for this were that:
- By 2006, across sub-Saharan Africa about one-quarter (26 percent) of households owned at least one mosquito net.
- By 2010, long-lasting insecticidal nets (LLINs) had become standard, distributed widely for full population coverage, seen as a public good and distributed free to end-users in many countries
There was a dramatic increase in ownership — in many countries 40 to 80 percent of households had one or more LLINs.
There has been strong involvement and engagement of stakeholders in the creation of the RBM programme:
- A national ITN task force, with representation from all partners, played a critical role in the scaling up of ITN coverage.
- In 2005, the framework was revised to represent the consensus of the RBM Partnership Working Group for scaling-up ITNs (WIN). It included representatives of national malaria control programmes, multilateral and bilateral organisations, research institutions, NGOs and the commercial sector.
- An overview of 20 African studies of RBM showed that the relevant stakeholders were engaged during planning and implementation and the ITN task force was coordinated across ministries, departments and sectors (e.g., health and retail). 
There was strong political commitment at the global level, as evidenced by the involvement and funding of many global organisations. However, national level commitment differs in each country:
- Before 2001, the bulk of ITNs used in Africa were provided through unsubsidised commercial markets, and there is evidence that these markets can grow rapidly when stimulated by public sector actions such as the reduction or removal of tax and tariff barriers, as had happened in many African countries by 2005.
- UNICEF supports the RBM ITN framework as a guide for national policy and programme development.
- The RBM partnership was launched in 1998 by WHO, UNICEF, UNDP and the World Bank and is the single global framework for implementing coordinated action against malaria. There are more than 500 partners, including malaria-endemic countries, their development partners, the private sector, NGOs, foundations, and research and academic institutions.
- WIN's membership includes national malaria control programmes, multilateral and bilateral organisations, research institutions, NGOs and the commercial sector.
- National support was patchy: for example, a 2010 report talks about the difficulty in working directly with the Government of Madagascar due to the political situation in the country, and hence the organisation in question had to engage the services of local faith-based organisations to distribute the nets at the community level. 
- In Kenya, though, from 2004 to 2006, there was an increase of nearly 10 times in the number of young children sleeping under ITNs in targeted districts, resulting in 44% fewer deaths than among children not protected by ITNs. 
Clarity of objectivesThe World Health Organization issued a recommendation in 2007 for universal coverage. This appears to have been an explicit shift in emphasis from targeted coverage (aiming primarily to cover children under five and pregnant women with ITNs) to protecting everyone in a community through the use of ITNs. 
Strength of evidence
The framework was issued by competent parties, which consisted of several stakeholders, and the programme employed the use of pilots, results of which were used to adapt to policy. Studies were also conducted to support the evidence, including similar previous programmes. The framework was produced by the Technical Support Network on ITNs.
Several studies have been conducted and pilot health programmes launched in support of the initiative, and results from the pilots were used to further refine approach throughout sub-Saharan Africa.
The presence of issues such as cost concerns, the stretching of timelines and sustainability of ITNs points to the fact that these concerns were not evaluated exhaustively at the outset. The problems were, for example:
- For the initial phase, the RBM target for ITNs was at least 60% coverage of high-risk groups by 2005. Many countries fell far short, although a number of countries accelerated coverage and were closing in on the target by 2005.
- There were several barriers to implementation, including costs to users for partially subsidised strategies, variation in implementation due to insufficient supplies of ITNs and vouchers, and poor communication and adherence to distribution procedures.
- At the policy level, there were insufficient financial resources to sustain current and future distribution strategies. There were ‘stock-outs', and poor logistics for ITN procurement and transport were common.
- There are serious concerns regarding the issue of mosquitoes becoming resistant to insecticides, and the threat that poses to the effectiveness of long-lasting ITNs. There is a need for more research on this issue, as well as a need for more investment in human resource capacity so that effective research, monitoring, and implementation of appropriate interventions can be carried out.
The global RBM programme calls for the creation of ITN distribution initiatives in each country along with a set of guidelines and recommendations. Hence, national-level management is subject to individual nations' governments. This helps in better delivery of the programme since the context is better understood at a national level. At the global level, there is a set of mechanisms and organisation structures within the RBM partnership. All actors involved in the management of ITN distribution are competent in delivering the programme.
Individual countries are often best positioned to know which actions are the most appropriate depending on the populations at risk, the level of transmission, the degree to which interventions are in place, and the capacity of countries' health systems to take these efforts further. The international community, on the other hand, plays a critical role by supporting countries and providing tools:
- Regional and national policies are reviewed consistently by the WIN. It concerns itself with broad strategies rather than detailed tactics, reviews the strategic options and makes recommendations based on experience to date.
- There is an RBM Monitoring and Evaluation Reference Group (MERG), which exists to discuss and analyse the mechanisms and issues involved in the activities of the programme. 
There are a number of measurement initiatives and MERG has met regularly to coordinate these measurement procedures and studies, which each country carries out under its aegis and using its resources, such as standard questionnaires.
There is a set framework and toolkit for monitoring and evaluating RBM programmes, which includes indicators to measure ITN distribution. Depending on the local context, countries can identify additional indicators to monitor implementation. For example ‘Gains attained in malaria control coverage within settings earmarked for pre-elimination: malaria indicator and prevalence surveys 2012, Eritrea', evaluated the impact of ITNs and other anti-malaria initiatives at the national level in Eritrea. 
However, the WHO's ‘World Malaria Report 2011' has revealed that when establishing impact of the ITN programme, many of the decisions were made informally and the reasoning was not made fully explicit.  There have also been a significant number of countries which have not made any data available.
Since the ITN programme is very broad, and involves several actors and stakeholders, alignment is a challenge. While efforts have been made by programme managers to equip all actors, there are some difficulties due to regional-level nuances. Governments have been proactive, but the involvement of all parties has been inconsistent, and there are problems in standardisation. Programme delivery also faces issues due to the lack of certain resources.
Results from 2005 showed that the development of sustainable mechanisms for supporting community-managed ITN programmes, particularly in rural areas, were not adequately served by the commercial sector or the public sector. It also showed that there was a need for standardised quality assurance and control procedures to be developed to ensure that institutional buyers and individual consumers were receiving effective ITNs.
Scaling up Insecticide Treated Netting Programmes in Africa: A Strategic Framework for Coordinated National Action, Roll Back Malaria Working Group
WHO releases new guidance on insecticide-treated mosquito nets, 2007 WHO Media Centre
World malaria report, 2011, WHO
Targeted subsidy strategies for national scaling up of insecticide-treated netting programmes - Principles and approaches, WHO
Defining and Defeating the Intolerable Burden of Malaria III: Progress and Perspectives, Uncertainty in Malaria Control in Tanzania: Crossroads and Challenges for Future Interventions, Leonard E. G. Mboera, Emmanuel A. Makundi, and Andrew Y. Kitua, Supplement to Volume 77(6) of American Journal of Tropical Medicine and Hygiene
The President's Malaria Initiative Sustaining Momentum Against Malaria: Saving Lives in Africa Fourth Annual Report, April 2010
INSECTICIDE-TREATED MOSQUITO NETS: a WHO Position Statement, 2009, WHO
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