(IVM) FOR Syria

               Prepared by

Intersectoral Committee on Vector Control

           Ministry of Health

              October 2006
1. Introduction
Recognizing the importance of vector-borne diseases in the EMR, Member Governorates
through Resolution (EM/RC.52/R.6) endorsed the Regional Strategic Framework for
integrated vector management (IVM) for the implementation of vector control. Member
Governorates also committed themselves to eensure that they have national capacity to
plan and implement IVM; allocate a specific budget line for IVM; establish a functional
intersectoral mechanism for the collaboration and coordination of all sectors in their
countries; and develop national IVM strategies and plans of actions. Such plans are to be
based on the carrying out of regular vector control needs assessment (VCNA) for all
vector-borne diseases to identify needs, gaps and opportunities for vector control.
Member Governorates on the other hand, requested the Regional Office of WHO in
addition to strengthening regional capacity in vector control to also provide countries
with guidelines to carry out VCNA in order to develop country-specific plans of action
for IVM.

Based on the guidelines developed by WHO/EMRO, Syria has carried out a detailed
VCNA though the activities of the Inter-Sectoral Committee (ISC) for vector control,
headed by the Ministry of Health (MOH). As a next step, the ISC has embarked on the
development of an IVM strategy and action plan to be discussed among a broader
consultation group who are equal partners of this approach.

The document in hand presents the national strategy for IVM in Syria, with a suggested
action plan, timeframe and estimated budget. After reviewing and amending this strategy
and action plan, it will be adopted by the appropriate political level.

2. IVM Background
The Division of Communicable Disease Control in the WHO Regional Office for the
Eastern Mediterranean strongly believes in the best utilization of available resources,
interventions and services at all levels of health care delivery. It is for this reason that the
Divison is actively promoting integrated disease management as a cornerstone of regional
and national strategies to control communicable diseases.

Well-planned and coordinated vector control interventions contribute significantly to
reduction of the incidence of vector-borne diseases. Effective vector control methods
exist, but their implementation as part of integrated disease management is limited. The
potential to use one or several of these interventions to address more than one vector-
borne disease exists and should be promoted. There is also a need to scale up some of
these interventions in a cost-effective manner.
    Within each zone, different species will have different ecological requirements.
    Knowledge of these requirements is fundamental to the development of integrated vector
    management (IVM), which bases itself on an ecosystems approach. An imbalance,
    caused by extreme weather conditions, floods or drought, or by human actions that
    change the hydrology or land-use patterns, can lead to explosive increases in vector
    populations with dire consequences for vector-borne disease transmission risks. Chemical
    interventions in agro-ecosystems, for example, can have similar adverse impacts.
    Strategies aimed at reducing disease transmission while maintaining or restoring
    ecosystem integrity are therefore needed.

    The widespread burden of vector-borne diseases or the risk of their re-introduction makes
    the control of vector-borne diseases a key component of health sector activities to protect
    and promote health. Moreover, due to the complexities of ecology, epidemiology and
    risks of exposure, these diseases are particularly important targets for intersectoral action
    for health.

    The key reason for employing an IVM strategy is to strengthen impact through
    complementary methods of vector control with operational flexibility, while respecting
    ecosystem integrity. Ideally IVM should reduce vector populations and receptivity to the
    point of preventing transmission risks.

    2.1. IVM strategy Framework

    IVM promotes public health policies and is based on the premise that effective control is
    not the sole responsibility of the health sector but requires the collaboration of various
    public and private agencies and communities. IVM also serves to extend the useful life of
    insecticides and drugs by reducing the selection pressure for resistance management. The
    IVM framework aims at addressing the deficiencies in vector control and improving the
    efficacy, cost effectiveness, ecological soundness, sustainability and intersectoral
    linkages towards attaining the Millennium Development Goals. It will serve as an
    advocacy tool for public health managers, environmentalists, development planners,
    project proponents and policy makers.

    - IVM general goal:

    The general goal of integrated vector management is the reduction of vector-borne
    disease mortality and morbidity, through the prevention, reduction or interruption of
    disease transmission in an environmentally friendly manner.

    - IVM specific objectives:

-    To reduce to minimum, where and when, possible vector breeding sites.
-    To reduce abundance and longevity of disease vectors.
-    To reduce human-vector contact.
-    To prevent the generation of new vector-breeding situations.
-    To involve relevant stakeholders as owners.
-    To empower communities as partners and beneficiaries.

    - Characteristic features of IVM

    Integrated vector management is a process for managing vector populations in such a
    way as to reduce or interrupt transmission of disease. Characteristic features of IVM
          - Methods based on knowledge of factors influencing local vector biology,
             disease transmission and morbidity;
          - Use of a range of interventions, often in combination and synergistically;
          - Collaboration within the health sector and with other public and private sectors
             that impact on vectors;
          - Engagement with local communities and other stakeholders;
          - A public health regulatory and legislative framework.

    2.2. Strategies for IVM

    The first essential step will be the incorporation of IVM principles and decision-making
    criteria into the existing framework of national health policies. Within this updated policy
    framework, a strategy for the planning, design, implementation, monitoring and
    evaluation of vector control interventions is developed with the following components:

-    Establishment or strengthening of vector control services, (within the Ministry of
     Health) in conjunction with: (1) the creation of an enabling policy framework for
     intersectoral collaboration, and (2) the strengthening of environmental health services,
-    Strengthening of the legislative and relevant regulatory framework and their
-    Social mobilization towards the involvement of communities in vector control
     activities, based on effective community IEC programs,
-    Capacity building addressing human, material and financial resources,
-    Promotion of research, and
-    Initiation and strengthening of regional collaboration.
3. IVM Strategic plan for Syria
3.1. Vector-borne diseases
The major vector-borne diseases in the country include malaria, Bilharsiasis and


Syria had suffered from endemic malaria. Up to the 1950s, malaria was endemic
throughout the country, except deserts and mountains above 1100 m, both P. vivax and P.
falciparum were present with predominance of the latter.

Malaria eradication program started in 1956, led to an interruption of transmission of P.
falciparum during the 1960s, in the course of a campaign using indoor DDT spraying,
with the cooperation with WHO. However, transmission of P.vivax continued at varying
degrees, mostly along the Turkey and Iraq borders.

During the 1990s, the maximum incidence of indigenous malaria was recorded in 1993
(966 cases), these cases were recorded in two provinces (Aleppo and Al Hasakeh), a
downward trend of malaria in Syria was observed from 582 cases in 1995 to 6 cases in

An outbreak of 63 local cases occurred in 2001 mainly in Ras El Ain district (55 cases)
and Al Malkeih district (8 cases) of Al Hassaka province bordering Turkey, then few
sporadic cases were found in communities along the borders with Turkey and Iraq.

In 2004, only one indigenous malaria case was reported in Al Malkeih district.

Al Hasakeh province, which has all indigenous Malaria cases, has an area of about
23.150 km2, and total population of 1.326.000 (7.4 % of total population).
The population at risk is estimated at 300,000 living in 110 villages in Al Hasaka

Malaria vectors include Anopheles Sacharovi, which is the primary vector, An. Claviger,
which is the secondary vector. An. superpictus and An. sergentii are also present but
they are of less importance.


Schistosomiasis is not essentially endemic in Syria. The old foci were in the northeastern
provinces bordering Turkey and Iraq along Belikh and Euphrates rivers during the
Second World War. The total number of positive cases ranged between 2,444 in 1987 to
433 in 1993; to only 1 case in 2004. The intermediate host is Bulinus truncatus. Only
five cases were reported during 2005 in AL Raqqa province.

Three different types of Leishmaniasis occur in Syria:
- Anthroponotic Cutaneous Leishmaniasis (ACL).
- Zoonotic Cutaneous Leishmaniasis (ZCL).
- Zoonotic Visceral Leishmaniasis (ZVL).

Cutaneous leishmaniasis is considered, at present, a big health problem, because of it’s
rapid spreading from two focused areas (Aleppo and Euphrates plain ) before 1960 into
eight provinces (wide distribution).

A. ACL (L. tropica)

It is the main leishmania problem, where 85% of CL belong to this form.
Main infected provinces are Aleppo and Edlib (northwestern); Lattakia and Tartous
(coastal region) and Hama and rural Damascus (center). The main vector of ACL is
Phlebotomus sergenti. The reservoirs are humans.

B. ZCL (L. major)

It represents about 15% of C L, where it is less endemic in Rural Damascus, Deir Ezzour
and Al Hasakeh. The main vector of this form is P. papatasi. Reservoirs are:
Psammomys obesus, Meriones sp. and Nesokia indicas.

C. ZVL (L. infantum)

The total number of reported cases is very low. It is distributed in villages of 4 provinces
including Edlib, Latakia, Aleppo and Dara’a. The main vector is P. tobbi. Reservoirs are
stray dogs.

In fact, the vast geographic distribution of leishmaniases and its spread over 300-500
villages make it hard to investigate its epidemiology and to control the vectors over such
huge areas. Therefore, insecticide spraying appears to be inefficient. Heterogeneity of
topography and land forms also makes it difficult to reach all infested areas to carry out
studies or control activities. Reluctance of the communities in new developed areas and
in rich districts towards insecticide spraying is also one of the factors leading to
inefficient control.

3.2. Situation analysis

1. Systems inputs

From the policy framework standpoint, the analysis reveals the presence of political will
within the highest level of the government including the President himself. This has been
translated into the formulation of several central and peripheral committees to coordinate
efforts directed to the control of vector-borne diseases especially leishmaniases.
However, this political will is not adequately reflected on the follow up of the actions of
the committees and their impact on the disease control. Lack of appropriate mechanisms
that would enforce and regulate intersectoral collaboration in the fight against the disease
as well as the lack of a national action plan and lack of scientific knowledge all
undermine the political commitment to disease control. In addition, insufficient financial
resources allocated to vector control operations also reflect the low level of political

The low level of political commitment creates no need to develop a separate policy for
vector control on the national level. The overall outcome of this situation is an inadequate
policy framework for vector control programs, a situation that would subsequently affect
the institutional and financial requirements of a strong program.

Although intersectoral committees are already established, their efficiency in dealing
with disease problems is still inadequate. Under epidemic situations these committees
receive strong support due to political stress, but as the situation eases less support is
seen. Consequently, intersectoral collaboration and stakeholders’ involvement still need
to be strengthened with a national plan of action where the role of each stakeholder is
clearly defined with sufficient technical, scientific and financial resources. This situation
affects both the institutional framework and the enabling environment for vector control.

Inadequate funding levels, on the other hand, negatively impacts the resource base
available for vector control programs. This directly leads to inadequate human resources
and facilities on both the central and peripheral levels. The problem of insufficient human
resources is actually more complicated than that of facilities, which might be solved by
direct spending to fulfill needs. It is evident that there is a great shortage in all categories
of the staff required for vector control operations. This is mainly due to three main
reasons: unavailability of the required specialties on the national level; low salaries
provided for the staff working in this field and better opportunities available for qualified
staff outside of the government health sector.

As the vector control program is mainly built on chemical control methods, with two
spraying campaigns per year, and due to lack of financial resources; the program depends
on temporary/seasonal workforce. As this manpower is seasonal, no continuous training
is provided to them. In addition, as the salaries provided to them are very low, most
workers refuse to cooperate with MOH or municipalities to do this job. The end result is
that the authorities would employ young persons (between 13 and 17 years of age) who
have no experience and awareness towards the use of pesticides. All these factors render
the chemical control activities inefficient while wasting the material and polluting the
environment without any measurable impact of vector populations. Another negative
impact is the exposure of this inexperienced workforce to chemicals as they tend not to
use protective cloths due to hot weather and lack of awareness.

Other underlying causes of vector control program inadequacy are related to the lack of
proper technical expertise. One very important shortage in the staff on both the central
and peripheral levels is the absolute lack of medical entomologists. Both the planning
    and implementation of control programs would require solid scientific knowledge about
    the vectors and reservoirs. Monitoring and evaluation would also require special
    expertise. Finding alternatives to chemical control methods also requires in depth studies
    of the ecoepidemiology including entomological factors, which are not adequately

    All of these factors synergistically contribute to insufficient human and technical
    resources available to the vector control program, without which any program would be
    greatly compromised. In fact, here the third group of factors (scientific and technical
    base of vector control) comes into play. Although there are several academic and
    research institutions that carry out research in the field of entomology and vector-borne
    diseases, the number of publications and available research during the last five years are
    very limited (10-15) and covers narrow areas of vector control. There are also very
    limited research in the field of vector ecology, biology and bionomics. There is also no
    government funding allocated for entomology and vector control research neither within
    MOH nor other institutions.

    This in addition to the lack of medical entomology specialists, basic research facilities
    (insectaries, field sampling gear, etc) and operational research agenda contribute to the
    inadequate research infrastructure. The parallel lack of national training institutions in
    the area of vector biology and control also underlies this problem. Thus, old retired
    expertise once available to the vector control program could not be replaced by new
    technically qualified staff. The outcome of this situation is the lack of
    training/educational opportunities on the national level as well as the inadequate
    scientific basis and technical guidance that could support the development of sound
    vector control policies and operations on the national level.

    Therefore, it appears that the three main groups of factors influencing the infrastructure
    of the vector control program have resulted in five main inputs, including:

-    Discontinuous political commitment to vector control
-    Inadequate financial resources for vector control
-    Inadequate enabling environment
-    Inadequate technical & human resources
-    Inadequate training
-    Poor scientific basis to guide vector control policies and operations

    These inputs collectively lead to an inadequate vector control program infrastructure,
    which would make the authorities struggle to achieve any desirable aims.

    2. Vector control processes, outputs and outcomes

    The vector control program inputs identified in the previous section would directly
    influence its structure, level of operation (processes), outputs and outcomes.
The position of the current vector control unit is lower in rank within the institutional
hierarchy of MOH than other departments. The vector control unit in the MOH is
replicated on the lower administrative units by 14 peripheral units. MOH has only
technical supervision role over the peripheral units (including provision of pesticides),
while their other financial resources are coming from the MOLAE. This works against a
proper coordination mechanism since the MOH controls only the technical part but have
no say on how the necessary logistical support (e.g. cars, equipment, etc) could be

From the financial point of view, insufficient funding leads to the appointment of what is
called “temporary” personnel for vector control field operations, whom are not qualified
for this technical task. Consequences on the quality of such operations are obvious.
There is also a shortage in facilities including those for office or field operations leading
to limited managerial and operational efficiency.

Lack of funds, facilities and technical expertise also contribute to the inadequate
monitoring and evaluation protocols for vector control activities, which are apparently
carried out only through supervisory inspections on the field operations.

In addition, no routine vector surveillance is carried out in sentinel sites. There is also no
system for pesticides resistance management. Lack of these operational tools definitely
influences the overall performance of the control program.

Vector control operations carried out by MOLGE is rather selective, targeted basically to
nuisance mosquitoes and flies and in most cases is carried out in response to complaints.
It is not based on solid knowledge on the mosquito species composition, its distribution
and ecology within the municipality. Again, the reason lies in the lack of specialized staff
and appropriate training.

In fact, fragmentation of vector control activities intersectorally; without appropriate
level of coordination and collaboration; weakens the institutional framework and may
result in redundant activities, cost-ineffectiveness and unsatisfactory program outcomes.
The lower rank of vector control unit within the administrative hierarchy of MOH may
reflect the level of importance given to it, which is further reflected on its financial,
technical and human resources.

All the above mentioned factors coupled with the insufficient level of scientific and
technical support for the vector control program contribute to the systems outputs which
are: the inadequate program development and implementation, inadequate vector control
and finally an expected increase in the vector-borne disease transmission risk.

In case the current vector control program’s inputs, processes and outputs prevails, this
system may lead, on the long term, to increased costs to the health sector as well as to an
expected increase in mortality and morbidity due to vector-borne diseases, especially
under the current state of new urbanization and increased population movement.
3. Framework for IVM

Although certain level of institutional frameworks exist within MOH and the MOLGE
that stress multisectoral involvement in vector and disease control measures, these have
not been translated into national policies and/or strategies for vector control including the
involvement of affected communities and NGOs. Vector control by the MOH is thus
carried out based only on year-by-year plans with no strategic directions.

Policies and regulations for EIA exist and integrate EH dimensions into the assessment
process. However, the vector-borne disease dimensions are not yet fully incorporated into
this system, although the EH directorate within the MOH is the responsible unit for
EHIA. This may show that intra-sectoral collaboration would also need to be

Experience in Syria has shown that new developments, especially urbanization, have
resulted in the formation of new foci for leishmaniasis thus spreading the disease over a
larger area, making it hard for authorities to respond to disease control. This situation is
not unique to Syria, but it is replicated in many other countries due to lack of awareness
which dissociates “environmental” impacts from health impacts of development projects,
where; as the term implies; environmental impacts are stressed and health ones
overlooked. Here again, the role of the ISC is emphasized to formulate a mechanism by
which the environmental health issues could be integrated into existing EIA framework.

4. Pesticides management issues

Pesticide management legislations and policies are currently in place; however, it is not
yet fully implemented and monitored, especially those aspects related to safe use of
pesticides and disposal of used containers. Transport of pesticides is not regulated yet.

Reasons behind this lie in the lack of technical expertise, funds and safe disposal
infrastructure in the country. In addition, evident lack of community and workers’
awareness regarding the environmental and health hazards of pesticides contributes to the
problem. This situation results in exposing public health, agricultural workers and
farmers to the risks associated with the unsafe use of pesticides.

Chemical poisoning data available for Syria revealed that the percentage of pesticide
poisoning cases ranged between 11 and 14.5% and that cases occurred in rural and urban
areas. In addition, unsafe practices currently used to dispose of used containers of
pesticides poses environmental threats related to pollution of soil, water and air.

Most of obsolete pesticides are not properly stored. At the present time, the Syrian
Government does not have the necessary capability and technical equipment to dispose of
these stocks in an environmentally safe manner.

Public health pesticides and related equipment are not exempted from taxes similar to
those for agricultural use, which are subject to lower taxes and tariffs. This reflects a
lower political commitment for vector control in comparison to control of agricultural

Therefore, there is a pressing need to formulate a plan to overcome current deficiencies in
pesticide management, an effort necessarily demanding intersectoral collaboration.

5. Community mobilization

A good level of awareness towards vector problems prevails among local communities.
Several cultural, societal and behavioral characteristics, however, may work against
vector control operations in target areas. This is mainly due to the nature of agricultural
and animal farming practices exercised in rural areas and perceptions and awareness in
urban ones. Meanwhile, hot weather during summer leads people to sleep outside their
homes with no protection, thus exposing them to increased number of vector bites.

The community structure and nature enable continuous communication with potential
awareness raising if the appropriate mechanisms are used. The local structures actively
involved in the communities, mainly the farmers and agricultural societies, would also
play a vital role in the anticipated community mobilization activities. In addition, MOH
through its Center for Preparation of Health Education Resources is in a good position to
lead these efforts in collaboration with the locals.

3.3. Rational

Based on the vector control situation and problem analyses for Syria and on the
identification of constraints facing the required performance level of program
implementation, the following needs are identified. These are listed in order of their
importance and their consequential impact on subsequent needs.

The identified needs are listed hereunder:

   -   Increase and maintain a sufficient level of political support to vector control.
   -   Restructuring of the institutional framework
   -   Secure a proper level of financial resources
   -   Strengthen intersectoral collaboration
   -   Bridge the gap in human resources
   -   Upgrade technical capabilities of staff
   -   Upgrade facilities and infrastructure
   -   Strengthen training and education infrastructure relevant to medical entomology
   -   Strengthen and support research on vector-related topics to provide an adequate
       basis for vector control program development and implementation
   -   Strengthen enforcement mechanisms of pesticide management practices
   -   Integrate vector-borne disease issues into current EIA system
   -   Raise community awareness regarding collaboration in vector control activities
   -   Identify control methods suitable for the different socio-cultural situations
4. Vision

By 2012 vector-borne diseases in Syria (including spread, emergence, or re-introduction)
are no longer a major public health problem.

5. Goal
To contribute towards the reduction of vector-borne disease burden and risk of re-
introduction/emergence in Syria by reducing vectorial capacity to the point of preventing
transmission risks. This is expected to contribute in the control of leishmaniases and
prevention of malaria and schistosomiasis transmission risk.

6. General objective
To implement integrated vector management for the prevention of vector-borne diseases
through the deployment of cost-effective and sustainable vector control interventions and
strengthened intersectoral coordination, partnerships and community empowerment.

6.1. Specific objectives
Specific objectives of the implementation of IVM strategic plan in Syria are to:
   1. Introduce and promote the IVM principles at national, governorate and locality
   2. Provide the appropriate political and institutional frameworks for IVM
   3. Strengthen the capacity for IVM planning and implementation at all levels
   4. Advocate for resource mobilization and efficient utilization for IVM
   5. Strengthen scientific basis for support of vector control planning and
   6. Promote the use of non-chemical vector control interventions and appropriate
      management of pesticides
   7. Strengthen intrasectoral and intersectoral collaboration and partnership, including
      community participation.

7. Targets
7.1. System-related targets

   1. By the end of 2007, a unit for vector control of all vector-borne diseases has been
      established in the MOH with appropriate mechanisms of intrasectoral
   2. By the end of 2007, IVM has been endorsed by relevant stakeholders as the
      national strategy for vector control.
      3. By 2010, 100% of governorates and 50% of lower administrative units have
          established structures for IVM implementation.
      4. By 2009, 100% of vector control units at the governorate level and 50% of all
          other administrative levels are led by at least one trained and qualified vector
          control trained person/entomologist.
      5. By 2011, 100% of governorates and 50% of lower administrative levels have
          established mechanisms for intersectoral collaboration and coordination for IVM
      6. By 2011, 100% of governorates and 50% of lower administrative levels have
          established mechanisms for community participation in vector control.
      7. By 2012, 60% of vector control activities are supported by partners.
      8. By 2012, 80% of peripheral units have an annual plan of action for vector control
          with at least 50% of the allocated budget received.
      9. By the end of 2007, all developmental projects; having vector-borne disease
          aspects; have included environmental health impact assessment in relation to
          vector-borne diseases.
      10. By 2009, pesticides related policies (legislation, regulations, standards,
          specifications and enforcement) will have been updated to serve vector control.

7.2      Technical/operational targets

      11. By the end of 2007, operational guidelines for the implementation of IVM for
          vector control are developed and disseminated at all administrative levels
      12. By 2009, human and institutional capacity for the implementation of IVM is
      13. 80% of house structures in targeted areas will be effectively covered annually
          with indoor residual spraying
      14. 85% of targeted households will have at least 1 LLIN for every 2 persons
      15. 80% of governorates and lower administrative units are implementing vector
          control interventions for immature stages (biological, chemical and

8. Monitoring and Evaluation
A monitoring and evaluation department will be established at the Vector Control unit in
the MOH. The responsibility of this unit will be to monitor the overall national IVM plan
at all levels of administration. At the governorate level there will also be a focal person
charged with the responsibility of monitoring and evaluation of IVM plan at this level.
Evaluation will be carried out every 2 years. Data for monitoring and evaluation will be
collected as part of the routine program activities and specialized surveys as needed.

The following indicators will be used for monitoring and evaluation at all administrative
levels as appropriate:
8.1. Impact

   1. % of reduction of the no. of cases due to vector-borne diseases
   2. % of potential vector-borne disease outbreaks prevented


   1. % of population covered with LLINs (for leishmania)
   2. % of population covered with IRS
   3. % of population protected by the other application methods

8.3. Process/ input

   1. % of targeted governorates and lower administrative units with established vector
       control units for IVM implementation
   2. % of targeted vector control units at all administrative levels led by at least one
       trained and qualified vector control person/entomologist
   3. % of targeted governorates and lower administrative units with established
       mechanism for intersectoral collaboration and coordination for IVM
   4. % of targeted governorates and lower administrative units with established
       mechanism for community participation in vector control
   5. % of vector control activities covered by partners
   6. % of targeted localities with an annual plan of action for vector control with at
       least 50% of the allocated budget received
   7. % of developmental projects which include environmental health impact
       assessment in relation to vector-borne diseases
   8. % of governorates units with updated pesticides related policies (legislation,
       regulations, standards, specifications and enforcement) to serve vector control
   9. % of the required budget received at national, governorate and lower
       administrative units levels
   10. % of target personnel trained in vector control and entomology
9. A basic framework for implementation of the IVM strategy
9.1. Preliminary phase

I. Formulation of a national IVM strategy

Development and implementation of an IVM program will require support from the
highest decision making levels. It is therefore necessary to incorporate the IVM strategy
into national health policies. The strategy will highlight the very crucial role of
preventive measures in disease control and will promote IVM approach. This strategy
should be harmonized with those for sustainable development and healthy environments.
This will require a strong collaboration, coordination and synergy between disease
control programs and programs for environmental health. As the national policies already
have provisions for vector control, they will be reviewed, updated or amended
continuously to take into consideration the strategies proposed in this framework.

Current status

This step has already moved forward through the work of the ISC including
representation of the relevant stakeholders. This has involved the finalization of a VCNA
report and an IVM national strategy. A national consensus workshop will be held where
the reports and the IVM strategy will be discussed among a broader group of stakeholders
and the necessary political commitments and implementation activities would be
reviewed. The next step will be the incorporation of IVM into national health and
development policies. However, it should be noted that this is an ongoing and continuous
activity that has to go parallel to all phases of implementation.

II. Building a core capacity for IVM implementation

In order to move ahead with implementation of the country action plan, elements related
to human and technical capacities should be set up. These will comprise a group of
trained personnel to initiate implementation in selected districts, an entomology
laboratory, communications and other logistical support systems.

Human resources
A group of these personnel will have to be trained on IVM principles and tactics and
refreshed on vector control techniques. This group should be trained as trainers where
they would further be able to initiate human resource development for IVM at country

It is also highly important to recruit one or two entomologists at the central level in order
to provide the necessary technical support for the IVM implementation. Several options
are available at the region where such expertise could be sought.
Setting up a national entomology laboratory
IVM is evidence-based and decision making for the selection of interventions is from an
analysis of the local epidemiological situation including ecological and entomological
surveys. In order to conduct these surveys, there will be a need to have a reference
entomological laboratory as part of the national public health laboratory service. This will
allow basic field entomology work for species identification, vector ecology and
bionomics, vector incrimination and bioassays including testing vector susceptibility to
insecticides, and, quality control of insecticide applications.

This laboratory should be equipped with all basic facilities and supplies to allow for
smooth operations, basic research and national training.

Communications and other logistical support
The national team responsible for IVM will need to communicate with all stakeholders,
link-up with partners within and outside the country, travel to the districts for field work
on IVM operations. Therefore, minimum logistical requirements will be established to
make the program operational.

Current status
Activities under this section are still in the planning phase.

III. Initiating the implementation of interventions in selected sites

Completion of the process described above will get the country ready to move to actual
implementation of interventions. In order to move consistently and efficiently, it is
recommended that a small number of sites (1 to 2) be selected to initiate operations and
from there move gradually to national scale as experience and results are gained.

The selection of such demonstration sites will be critical in order to guarantee success.
Criteria for demonstration site selection may include:

   1- Number of existing/potntial vector-borne diseases
   2- Level of past/current disease burden/endemicity/risk of transmission
   3- Proportion of population at risk of the different vector-borne diseases
   4- Capacity of vector control available in the area (number of trained staff, resources
       available, physical infrastructures etc)
   5- Level of political commitment
   6- Acessibility of the area all-year round
   7- Type and level of vector control intervention currently implemented
   8- Level of community willingness to support vector control programs
   9- Existance of other programs that may provide additional support to vector control

Once demonstration sites are selected, the site-level planning process will then take place.
This process entails the following:
1- Setting priorities
2- Situation analysis: epidemiological, entomological and ecological assessments
3- Setting objectives and targets
4- Designing interventions
      - Selection of options
      - Feasibility assessment
      - Combination of methods
5- Elaboration of site-specific IVM operational plans
6- Implementation of activities, monitoring, evaluation and reporting for adaptive

Current status
Activities under this section are still in the planning phase.

IV. Community mobilization

Community involvement will be an essential element for planning, implementation,
monitoring and evaluation of vector control interventions. Effective vector control
interventions will require active participation of communities. Community mobilization
is a key to this process. This will be conducted with the view of improving, overall, the
status of their environment, and concomitantly, impacting on disease transmission. An
important work with communities is supporting them to express the need for healthy
environments will be required.

This has to be coordinated between all stakeholders taking advantage of the existing
programs or ongoing projects (e.g. farmer schools, extension engineers, etc). Special
expertise will also have to be involved with the ISC to plan, implement and follow up this

Current status
Activities under this section are still in the planning phase.

9.2. Consolidation phase

Further and parallel to the completion of the introduction phase and in order to ensure a
smooth transition to the scaling up, the consolidation phase will have as objective, the
preparedness of the country before the scaling up of IVM interventions. This will include
the following;

B.1. Functionality of IVM structures

IVM requires a national coordination structure with a multi-sectoral representation. The
ISC will have to be broadened to include adequate representation from all major
stakeholders. The ISC will have to operate on an official basis through its establishment
by the appropriate authority in the country and with appropriate and clear terms of
reference. It will oversee the IVM program in the country and ensure that all activities of
stakeholders are adequately streamlined in the program. It will also address inter-sectoral
issues such as policy and legislation on pesticides including the role of IVM in the
implementation of the Stockholm convention on POPs. The ISC will finally review and
adopt the IVM program plans and annual reports including mechanisms for their funding.

IVM advisory committee within the ministry of health
Within the ministry of health it will be critical for all vector-borne disease control
programs to have a forum to explore synergies and to ensure integration of vector control
activities under the umbrella of IVM. The committee will be composed of managers of
vector borne disease control programs implemented in the country including the IVM
focal point, representatives from research and academic institutions. The committee will
be a subgroup of the ISC. It will address programs’ vector control common issues such as
capacity building, financing, monitoring and evaluation and advice ISC on technical

Similar structures may also be formed on district and peripheral levels in order to ensure
proper coordination, monitoring and evaluation of IVM activities.

B.2. Implementation of supporting IVM activities

There are a number of supporting activities that will have to be implemented complement
IVM activities. These include formulation of policies, legislation, regulation, monitoring
and reporting, quality control and evaluation functions and operational research.
Although some of these activities have already been started as part of the VCNA, such
activities should be regarded as a continuous activity.

Formulation of policies and legislation

One of the thrusts of IVM is the inclusion and implementation of policies and legislation
among its intervention to mitigate the proliferation and spread of disease vectors and
other consequences such as development and spread of vector resistance to insecticides.
The IVM focal person within the ministry of health will have the responsibility to
continuously assessing the gap in policies and legislation and most importantly to
propose to the respective IVM committees’ actions to be taken to fill these gaps. The
committees will therefore have to formulate recommendations to policy makers for
putting the needed policies and legislation in place and for their enforcement.
This process has already started within the framework of the VCNA. However,
executive actions need to be implemented. This step should be regularly repeated as need


A number of stakeholders undertake activities that can result in a worsening of the vector
situation. For instance, private companies offer residual house spraying, sometimes using
insecticides that are either obsolete or no longer recommended; or, development projects
are still taking place without the necessary health impact assessment and the planning of
mitigating actions for disease vectors. The IVM program will undertake activities to
ensure that the Ministry of Health fully plays its regulatory role in such activities.

Quality control of IVM product

A system will have to be established and activities developed to ensure quality control of
IVM products such and pesticides, application equipment, fabrics etc. WHO and other
partners will provide technical support to the IVM process in the implementation of this

Monitoring and evaluation

The IVM will have to define indicators and methodologies for monitoring and evaluation
of IVM activities. This will depend on the epidemiological situation and the designed
objectives and targets.

Operational research

Effective IVM implementation depends, inter alia, on sound background knowledge of
the vector populations, their ecology, bionomics, insecticide resistance status and
vectorial capacities. Operational research addressing these issues is a fundamental
cornerstone of IVM planning and efficiency. Cooperation between MOH and scientific
institutions is thus highly required.

B.3. Capacity strengthening

Capacity strengthening will focus on human resource development. During the
consolidation phase, the IVM program will have as one of the major activities to train a
sufficient number of health personnel on IVM for all districts. It is estimated that at least,
one health personnel will have to be trained on IVM. This will ensure a good technical
readiness of the country to take interventions to scale. In order to achieve this, the
establishment of national training courses on IVM and related entomological aspects is
advocated for. Training of personnel outside the health sector is also an important step
towards scaling up and effective implementation and coordination among relevant
9.3. Expansion Phase

The expansion phase will be the scaling-up of IVM interventions in all possible districts
in the country. It is believed that the introduction and the consolidation phases will build
the necessary foundations to take IVM to scale. During the expansion phase, the focus
will be to move the management of IVM operations from the national level to the district
level. This will require the replication of most of the structures and functions established
at the national level to district level and in compliance with the national orientations for
decentralization of health structures, functions and activities. And additional effort will
be required to ensure the availability of the necessary technical, human and financial
resources at that level for a proper implementation of activities.

9.4. Funding

A separate budget for IVM should be allocated on the central level as it would cover
activities targeting all vector-borne diseases. In case, vector control would still be as a
component of disease control programs, IVM budget should be shared by all programs in
a coordinated fashion. Stakeholders involved in the national IVM implementation should
also share in the budget and financial burdens. Mobilization of additional financial
resources will be an important and necessary activity of the ISC.

MOH may also allocate part of the vector control budget for IVM supporting activities.
Also, parts of the biennium or country budgets provided by WHO may be allocated to
support training, facilities or equipment as part of the IVM budgeting process. Finally,
the UNEP/GEF project will provide a good opportunity to fund parts of the suggested

10. IVM Action Plan, Timeframe and Budget
A suggested general action plan and timeframe is provided in Table 1 below. A detailed
plan of action with estimated budget is presented in table 2.
     Table 1: Action Plan and suggested timeframe of the IVM strategy

       Interventions                       Actions                  Timeframe
I. Develop IVM strategy        ISC to develop a national IVM       Done
II. Supporting activities to
- Policy,                      -   Formulate policies,            Starting from
legislative/regulatory,            regulations and legislation    year 1.
institutional frameworks and       that would enforce IVM, and
advocacy                           minimize/prevent activities
                                   that might worsen the vector
                               -   Integrate IVM into national
                               -   Upgrade the institutional
                                   structure of IVM (all vector-
                                   borne diseases should be
                                   under one administrative unit,
                                   and vector control should
                                   attain a higher administrative
                                   level to support all vector-
                                   borne diseases’ programs).
                               -   Incorporate health issues in
                                   the existing EIA system.
- Functionality of IVM         -   Expand ISC                     Year 1-4
structures                     -   Upgrade the legal status of
                               -   Establish IVM advisory
                                   committee in MOH to
                                   coordinate, update and advice
                                   national plans for all vector-
                                   borne diseases
III. Capacity
- Basic human resources        -   Designate 1 staff as IVM        Year 1
                                   focal point
                               -   Select 2 staff as IVM core
                               -   Train staff on IVM principles
                                   & tactics
                               -   Train 2 staff on
                                   entomological field
                               -   Train 2 staff on managing
                                   entomology lab
- Building human resources           Based on identified needs:            Year 1- 5
at the national level            -    Use in-house trained
                                      personnel to train others.
                                 -    Send staff for training
                                      courses outside the country.
                                 -    Recruit at least one
                                      entomologist to manage
                                      vector control activities on
                                      the national and peripheral
                                      levels. Alternatively, qualify
                                      staff members on medical
                                      entomology using EMRO
                                      regional network.
                                 -    Carry out refreshing courses
                                      on the national level.
                                 -    Allocate part of the biennium
                                      money and/or WHO’s
                                      country budget for training.
- Establish a quality control    -    Select appropriate spaces          Year 1-2
entomology laboratories          -    Design & finish the labs
                                      internal conditions
                                 -    Procure equipment &
- Communications &               -    Up-to-date PCs                     Year 1-2
logistical support               -    Fast internet connection
                                 -    Photo copy machines
                                 -    Fax machines
                                 -    Basic entomology field
                                      sampling gear (for aquatic &
                                      adult stages)
IV. Operations
- Community mobilization         -    Select a community                 5 years
                                      development specialist             (this is an
                                 -    Develop a community                ongoing
                                      mobilization plan                  activity with
                                 -    Establish partnerships with        decreasing
                                      ongoing activities                 costs over
                                 -    Implement plan (seminars,          time)
                                      workshops, training of locals,
                                      media, brochures, etc)
                                 -    Involve NGOs, donors,
                                      community structures,
                                      municipalities & other
- Site(s) selection & priority   -    Use criteria to select 2-3 sites       Done
setting                               for demonstration
                              -   Identify priority actions
- Site-specific situation     -   Epidemiological assessment      Beginning of
analysis                      -   Entomological assessment        year 2
                              -   Ecological assessment
- Updating objectives &       -   Based on situation analysis     Second half of
targets & designation of          results, review and update      year 2
site-specific interventions       identified targets
                              -   Designate interventions in
                                  coordination with
                                  stakeholders & communities
- Develop site-specific       -   Develop plan of action          End of year 2
operation plan                -   Designate roles &
                                  responsibilities for involved
                              -   Allocate budget
- Implement plans in                                              Year 2-5
demonstration sites
V. Operational research       -   Identify priority research     Starting from
                                  questions addressing needs     year 1.
                                  for IVM planning and
                              -   Establish partnerships with
                                  research institutions with
                                  relevant interests and
                              -   Allocate part of the MOH’s
                                  vector control budget to
                                  operational research.
                              -   Apply for additional financial
                                  support through TDR small
                                  grant scheme.
                              -   Use UNEP/GEF to support
                              -   Incorporate research results
                                  into IVM actions
                              -   Continuously review and
                                  update priorities.
VI. Monitoring &              -   Develop an M & E system on       Starting end
Evaluation                        the national level.               of year 1
                              -   Identify indicators for
                                  monitoring and evaluation
                              -   Implement regular M & E
                                  and adaptively manage the
                                  IVM plans of actions based
                                  on the results
- QC of IVM products          -   Develop a QC mechanism for Starting end
                         IVM products as part of the   of year 2
                         M & E system.

VII. Dissemination   -   Disseminate experience and    Year 2-5
                         success stories
                                        Table 2: Estimated Budget for IVM strategic plan of Syria
Intervention areas                                           Activities                                      Budget in USD   Remarks

Policy, planning and      Conduct orientation meetings with policy-decision makers for IVM                         10,000
advocacy                  Revise and reform the supportive legislations for IVM at all levels                      20,000
                          Strengthen legal and institutional position of ISC for IVM role at the national           5,000
                          Establish a vector control advisory group at the national level                          15,000
                          Incorporate the IVM strategic plan into the national health policies                     30,000
                          Negotiate and establish a vector control unit for all VBDs at central,                   25,000
                           governorate and locality levels
                          Develop IVM plans at national and governorate levels with the involvement of             75,000
                           relevant actors
                          Mobilize and sustain resources to implement IVM                                           7,000
                          Enhance the partnership with private sector and NGO’s for IVM                            10,000
                          Conduct regular coordination meetings of the ISC for IVM at different levels             30,000
                          Print and disseminate the IVM strategy at all levels of administration                   20,000
                          Strengthen communication with stakeholders for IVM through established                   10,000
                          Develop and print IVM advocacy materials                                                 20,000
                          Involve mass media and press in the planning and implementation of IVM                   20,000
                          Ensure the involvement of health sector (vector-borne diseases) in the impact            15,000
                           assessment of any developmental projects with potentially relevant aspects
                   Integrate IPM farmer’s field schools and agricultural extension engineers         75,000
                    within IVM plans
Capacity           Establishment of a vector control unit for VBDs at all levels:
strengthening        Recruitment of personnel – including one qualified vector control
                    person/entomologist for each level of administration                              50,000
                     Training (basic) of the senior staff of the units                              120,000

                     Furnish the unit with basic needs                                              100,000

                     Avail transport and communication facilities for the units                     500,000

                     Avail entomological field surveys gear for the units                           300,000

                   Establishment of entomological laboratories and insectary facilities             300,000
                   Establish an appropriate academic training curricula for mid and senior level     50,000
                    entomologists/vector control personnel in cooperation with national and
                    regional experts
                   Provide technical support through the recruitment of consultants                 100,000
                   Provide advance training and staff development courses for approximately 10     1,150,000
                    trainees each year
                   Provide training in GIS for 7 staff to support all administrative levels         140,000
Operations         Conduct site-specific situation analysis (epidemiology, entomology and           280,000
                   Spray 1,500 hectares [190,000 population] every year using appropriate           300,000
                   Apply appropriate immature-stage control intervention/s where these are          800,000
                   Assess the coverage and quality of vector control interventions                   80,000
                 Procure and distribute 600,000 LLINs for free in rural areas using the COMBI           3,600,000
                 Map the distribution of vectors, breeding habitats, reservoir territories and            400,000
                  VBD cases using GIS, with continuous updating
                 Conduct demonstration activities for IVM in 3 selected demonstration sites          2,000,000
                 Mobilize and empower communities and community-based organizations                        40,000
                  (CBOs) for their participation in vector control
               Conduct a refresher-training for teams responsible for the quality application of           75,000
                  vector control interventions in the field
               Support salaries of temporary spray teams (additional incentives)                          200,000
               Provide personal protective gear for vector control teams according to standard            100,000
                  international regulations
               Provide training for vector control teams on safe use of insecticides & disposal           100,000
                  of used insecticide containers
               Provide training on insecticide stock management, safe handling and                         70,000
               Purchase one pump for every person responsible for the application of vector               250,000
                  control interventions
                 Procure and distribute 30,000 kg, 5,000 litres, and 75,000 litres of insecticides      1,600,000
                  for house spraying, chemical larviciding and space spraying, respectively on an
                  annual basis according to WHOPES specifications
               Monitor resistance of vectors to insecticides in selected sentinel sites to guide          150,000
                  the choice of insecticides and contribute to an overall management strategy
Operational      Identify the role of reservoirs in leishmaniases epidemiology                            120,000
research                 Apply PCR technology to assess infection and incriminate vectors of                120,000
                         Use PCR technology for leishmania species typing to assist in epidemiological       80,000
                         Investigate sand fly ecology and bionomics in hot spot foci                        140,000
                         Identify environmental/landscape risk factors for leishmaniases using GIS          100,000
Monitoring      and    Establish a system for regular entomological, rodent and malacological surveys       140,000
evaluation                at all levels for better utilization of vector control interventions
                       Provide regular supervision at all administrative levels                              75,000
                       Conduct regular review and planning meetings for vector control within the           100,000
                          IVM framework at all administrative levels
Dissemination          Disseminate experience and success stories through web site development,             200,000
                          printed material, scientific publications and networking
Total budget                                                                                              14,317,000

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