• Identify and promote public/private-sector partnerships for sustainable ITN use.
  

• Advocate integrated approaches for the promotion of insecticide treated net use.
  
• Serve as a platform for special issues, for example, the rationalization of taxes on nets and insecticides.
  
• Share information and experiences.
  

• The role of the Roll Back Malaria Global Partnership in the wide-scale use of Insecticide treated Nets.
  
• State-of-the-art research.
  
• Respective roles in public/private partnerships.
  
• Removing barriers to trade in bednets and insecticides.
  
• Building strategic frameworks for developing national eradication strategies.
  
• Technical and operational implementation issues related to retreatment; safe use of insecticide; assessment, monitoring and evaluation tools.
  

The conference dealt with many issues of great importance to the NGO community, including the role of NGOs in meeting the challenge to provide 60 million African families with insecticide treated mosquito nets over the next five years. Last year 70,000 African children died from malaria when a $4 (U.S.) bednet could have saved them. A recent review of bednet studies conducted by the Cochran Collaboration found that those children who slept under treated bednets were 50 percent less likely to develop malaria compared to control groups.
Malaria and health development experts at the conference agreed that a number of strategies are needed to increase the availability of bednets. They include:

• Iincreasing local production and demand.
  
• Public/private partnerships to bring down the cost of bednets, and develop markets.
  
• Encouraging the governments of endemic countries to remove all tariffs on bednets and insecticides.
  
• Encouraging private and public donors to subsidize the provision of bednets for those who cannot afford them.
  
• Educating affected populations on the need to regularly retreat bednets with safe insecticide.
  

Commercial marketing strategies are expected to play a major role in increasing the availability, usage, and retreatment of bednets. It is estimated that with social marketing campaigns combined with subsidies, the price of a treated bednet could be lowered to less than $2 (U.S.) making bednets an affordable and desirable purchase for even the poorest of families.

How the ITN Intervention Developed

The pioneering work on the entomological efficacy of ITN's opened the door for the necessary morbidity trials, which in turn, paved the way for the essential, but costly large-scale mortality trials that have produced such compelling evidence to qualify ITNs as a credible and essential public health intervention. Then came the test of translating efficacy trials to effectiveness in real-life settings. This led to large numbers of relatively small-scale operational experiences with a variety of public, private, and mixed sector implementations, some of which have been assisted by TDR's Operational Research Network. These steps have brought us on schedule to the present.
The challenge now is to go beyond these projects, to change behavioral norms so that in the future, protection in malaria-endemic areas would be available to all through a system providing high access and high utilization of ITNs—in other words, moving towards the culture of net use and of net retreatment. This challenge presents a clear opportunity to NGOs who work at the community level.

From Projects to Programs

A series of case studies were presented from countries where insecticide treated bednets have already seen considerable use. These include Vietnam were insecticide is provided free by the government and low-cost nets are produced and purchased by all but the very poorest of families. In Tanzania where three net producers exist, social marketing of bednets is in process. Both Zambia and Ghana are pursuing public/private initiatives. But much more needs to be done if the target of a 30-fold increase in use of insecticide treated materials and effective vector control is to be realized in Africa.

The consensus of the meeting was that ITN usage has reached a critical juncture where linear scaling up may simply not work. ITNs are now universally accepted as an efficacious, essential, public health intervention. Promotion of ITNs is now mentioned in most national malaria strategies, yet we are a long way from high coverage and access.

Rough estimates of the production needed to reach desired coverage with bednets in Africa are more than 32 million new nets per year and over 320 million retreatments per year. Obviously we cannot rely entirely on commercial nets and insecticide producers for this coverage; there is a need for creative financing and pricing practices carried out with the facilitation of NGOs in order to boost demand and stimulate the private-sector to gear up for the necessary market. Some examples are: credit with repayment over time, cross-subsidy approaches, subsidy for retreatment and finally, subsidy for targeted initial distribution of nets. Everyone agrees the nets should be sold together with insecticide with the user making the first application. Subsidies should be so targeted that they cover only the poorest of the poor; any leakage of subsidized nets back into a black market would discourage private commercial sector efforts.

For the NGO community, we can act as a broker between the producers of both nets and insecticide and communities we serve. Economies of scale are potentially available when NGOs combine their orders for a preferential factory price. The net producers seem willing to entertain such bids since most of them now are producing below their peak volumes.

To assist NGOs in locating both nets and insecticide supplies, UNICEF has stationed Mr. Frans Claassen in Pretoria, South Africa. He will not serve as a purchasing agent, but can give guidance and technical assistance. His e-mail address is: fclaassen@unicef.org.za

Several constraints and suggested solutions were identified and discussed as shown below: