Abstract:
Indoor residual spraying (IRS) and insecticide-treated nets (ITNs), two principal
malaria control strategies, are similar in cost and efficacy. We aimed to describe
recent policy development regarding their use in Mozambique, South Africa and
Zimbabwe.
Methods Using a qualitative case study methodology, we undertook semi-structured
interviews of key informants from May 2004 to March 2005, carried out
document reviews and developed timelines of key events. We used an analytical
framework that distinguished three broad categories: interests, ideas and events.
Results A disparate mix of interests and ideas slowed the uptake of ITNs in Mozambique
and Zimbabwe and prevented uptake in South Africa. Most respondents strongly
favoured one strategy over the other. In all three countries, national policy
makers favoured IRS, and only in Mozambique did national researchers support
ITNs. Outside interests in favour of IRS included manufacturers who supplied
the insecticides and groups opposing environmental regulation. International
research networks, multilateral organizations, bilateral donors and international
NGOs supported ITNs. Research evidence, local conditions, logistic feasibility,
past experience, reaction to outside ideas, community acceptability, the role of
government and NGOs, and harm from insecticides used in spraying influenced
the choice of strategy. The end of apartheid permitted a strongly pro-IRS South
Africa to influence the region, and in Mozambique and Zimbabwe, floods
provided conditions conducive to ITN distribution.
Conclusions Both IRS and ITNs have a place in integrated malaria vector management,
but pro-IRS interests and ideas slowed or prevented the uptake of ITNs.
Policy makers needed more than evidence from trials to change from the time-
honoured IRS strategy that they perceived was working. Those intending to
promote new policies such as ITNs should examine the interests and ideas
motivating key stakeholders and their own institutions, and identify where
shifts in thinking or coalitions among the like-minded may be possible
