Insecticide-treated nets mass distribution campaign: benefits and lessons in Zambia

The Ministry of Health and partners developed a comprehensive micro-plan for the 2014 mass distribution. This contained details on processes and a roadmap, overall needs (after conducting a rigorous gap analysis) and the procurement plans, roles and responsibilities for national (central), provincial and district level to guide the mass campaign (Table 2). Provincial and district health staff and communities (including area chiefs and traditional leaders) were informed 6 months earlier of the mass campaign plan to conduct mass distribution. This earlier notification fostered ownership and allowed the community leaders, chiefs and volunteers to have adequate planning and orientation in their catchment areas. In addition, several workshops were held with provincial and district planners, and, District Malaria Focal Points to ensure that each province or district clearly understood the scale of logistics to conduct the mass distribution.

The National Malaria Control Programme also ensured that community structures such as neighbourhood health committees (NHCs) were linked to the district level during micro-planning to enable accurate estimation of LLINs and the number of days required for the delivery. The mass campaign plan also developed templates that contained information on household sleeping spaces (Table 3), human resource requirements, quantities of mosquito nets, transport, finances for activities and logistics on LLIN distribution required within the district and health centre catchment area as well as a mechanism for coordinating distribution and community engagement at district and community levels. Macro plans were validated by the central level, i.e., National Malaria Control Programme.

A total of 6,646,500 LLINs were procured for this campaign in 6 out of 10 provinces of Zambia. The other 4 provinces were covered with LLINs during a rolling mass distribution the previous year. Seventy per cent of the total budget of 20.6 million Zambian Kwacha (approximately USD 4.1 million at the exchange rate then) was spent on procurement of LLINs for mass distribution; and, the rest was spent on miscellaneous, including freight, insurance, and programme management, transportation from the central storage (hub) to health facilities and on the distribution from health facilities to end-users. United States dollars (USD) 5.07 per net included; cost of the LLIN plus distribution (to end user) and community mobilization.

To explore improved efficiency of supply methods, direct distribution from supplier to the district was conducted. However, there were some deliveries which still passed through the national (central) level storage area in Lusaka (Fig. 1). To achieve a direct delivery, the supplier or manufacturer was requested to distribute a quarter of the 6,646,500 LLINs from source of supply directly to districts without passing through central storage in Lusaka, the capital city of Zambia (Fig. 1). This study found that direct delivery eased storage bottlenecks.

Internal quality assurance (QA) was conducted at the factory stage but verifications were done independently facilitated by United Nations Development Programme (UNDP) on behalf of the national health authorities. The internal quality checks were in conformity with WHO recommendations. This internal quality assurance included; checks on physical characteristics-stitching, trimmings, labelling, weights, sizes and cleanliness. Likewise, “external” quality assurance was conducted prior to distribution, 14 samples of LLINs from different batches were sent to a Research Centre in Belgium at Wallon, Gembloux to assess physical and chemical analyses such as stress analysis, insecticide content, isomer ratio, fabric weight, insecticide wash resistance index, netting mesh size, dimensional stability to washing and bursting strength of the net fabric and seams. All the samples conformed to the WHO procurement and use of LLIN for malaria control requirements.

A quarter of the overall 6,646,500 LLINs procured for the mass distribution in 2014 was distributed by the supplier directly from the manufacturer in Arusha, Tanzania to provincial storage areas (hubs) and then to health centres. The remaining 75% of the LLIN consignment was transferred initially to central storage hub in Lusaka (capital city of Zambia) from where the World Food Programme (WFP) transported them to designated network of eight strategic in-country provincial storage areas (hubs) managed warehousing by trained WFP staff. The WFP leveraged 900 trucks from the local truck association. The local truck association was well placed in navigation through tough terrain to remote areas, under tight delivery schedule/timelines to distribute LLINs to 974 health centres for distribution by CHWs to communities. From health facilities the MOH and CHAZ facilitated the door-to-door distributions through the involvement of CHWs. CHWs form a link between local health system and communities.

World Food Programme used new technology—a specialized Relief Item Tracking System (RITA) developed and maintained by WFP logistic staff in Rome, Italy. This mobile-based technology involved assigning a Quick Response Code to each batch of LLINs linked to Geographic Positioning Location obtained at each locality by WFO staff and delivery information. By scanning the Code with a mobile phone, the WFP and partners were able to quickly identify where and when LLIN were dispatched and to transmit daily accurate, well maintain records (data) on LLINs consignments. RITA tracking system facilitated the step-by-step tracking of LLIN movement on each route for each truck from central warehouse to the health facility. Thus, WFP ensured availability timely, of LLINs at the destination point, in good condition, in right quantities with minimum loses while in transit (only about 0.08%).

Household data for each catchment area, including sleeping spaces registered collected from community registers, were used to develop a detailed district micro plan that indicated the needed human resources, quantities of mosquito nets, transport, finances and other logistics required for each health centre catchment area. To avoid discrepancies in the LLINs requirements for each household, rigorous verification of the LLIN data was done for each district in collaboration with health centre before LLINs were transported from the health centres to various point of use by CHWs. In terms of field validation, data used was at the household level; it included data elements such as name, village, number of persons in each household and the LLINs required. The districts in these provinces were engaged to show examples on any erroneous entries that were subsequently corrected in the registers and the database. An additional 5% random re-sampling was conducted to validate this data. The register were then returned to the health facilities and used as a basis for distribution of the LLINs to the households, indicating how many LLINs were given to each household. These were then re-entered into the excel database and a comparison of need that was actually received was conducted to estimate the LLIN gap by household. These efforts were facilitated by a multi-disciplinary Monitoring and Evaluation Technical Working Group that supported analyses and advice.

To ensure effective coordination of the mass distribution efforts, the National Malaria Control Programme (NMCP) plan involved constituting coordinating committees, specifically for the mass ITN campaigns with defined terms of reference (TORs), mainly focusing on ensuring smooth operations of the procurement, commodity tracking, distribution, monitoring and evaluation, community mobilization/sensitizations and holding of a series of meetings before, during and after the mass distribution campaign. The new committees (Table 2), worked with the already existent structures in the NMCP such as ITNs, M&E, and IECs Technical Working Groups (TWGs) at national, sub-national or provincial level to community level to implement the planned activities.

At the sub-national level, coordination was mediated through the Provincial Medical Officers (PMOs) and the District Medical Officer (DMOs) working with district-level Malaria Task Forces (MATF). MATF consisted of heads of Government departments, Local Municipal Council authorities, parastatal bodies, business community and non-governmental (NGOs), including Churches Health Association of Zambia (CHAZ). The PMOs supported development and implementation of the micro-plans, logistics and administrative arrangements required for effective delivery of LLINs to communities, while the DMOs worked with MATFs to coordinate implementation at the district level. At the health facility level, Health Centre Advisory committees linked the district MATFs with community structures (neighbourhood health committees, area chiefs and religious leaders) to mobilize full community participation or action that included enumeration of households, door-to-door distribution of LLIN, and delivery of key messages to promote effective use and discourage misuse of LLINs. At the community, area chiefs, traditional leader’s support was particularly valuable.

The use of mobile phone technology enabled monitoring of progress on LLIN distribution in all areas including, hard-to-reach areas at subnational level which had previously not received real time monitoring. Community volunteers at each health center collected data on a number of households, sleeping spaces and the number of LLINs required at each household. The data was aggregated and sent through health facilities to district office where it was further validated and submitted to the national (central level) for use in coordinating the mass distribution and production of the final report.

The National Malaria Control Programme staff trained in ITNs for malaria vector control/elimination and logistics management supported by partners served as master Trainers of Trainers (ToTs) of district staff who in turn cascaded training to health facility and community levels. Sixty-four Provincial and 1161 district staff were trained including, planners, environmental health technologist, nurses and clinical officers in-charge of operations at health facilities. At the district the training initially started with health centres-in-charge who then cascaded it to CHWs; the cascades helped to train, coordinate and supervise community volunteers from neighbourhood health committees. The training also provided skills on registration of households, data collection tools, and data verification using national malaria training manuals adapted from WHO guidelines built on lessons obtained from other national malaria programmes in the African sub-region.

Immediately after training community members were provided with information, education and communication materials which they used to deliver key malaria messages. They were also provided with registration forms for the them to use in registering sleeping spaces in the household in their respective catchment areas.

Each partner brought unique comparative advantages to the mass campaign. The United Nations Children Fund (UNICEF) facilitated LLINs procurements given their expertise in long-term agreements with WHO-certified pharmaceutical product suppliers. UNICEF also financed the development of malaria messages and radio programmes during and after distribution. The UNDP strength in project management, supported MOH’s coordination/management of the whole process. WHO’s strengthen in development of strategic documents and guidelines coordinated the development of comprehensive technical and financial gap analysis for the LLINs in collaboration with the US President’s Malaria Initiative, Malaria Control and Elimination Partnership in Africa and other partners. The gap analysis was built on various assumptions that took into account several factors including, target population for the LLINs, source of funds (assured or not), unit cost for the delivery of one LLIN to the household. The gap analysis also took into account the average user-life of an LLIN, costs for community mobilization, IECs production and advocacy. To enhance quality delivery, the gap analysis was validated through a peer review team of experts and consultants from the regional and global malaria partnership. These were skilled in project planning, procurement, supply and distribution management. The use of Gap Analysis Excel spreadsheet (tool) has over the past 5 years evolved. The WHO Global Malaria Programme has provided technical support which has strengthened capacities for vector prevention commodity, case management and programme gap analyses in the malaria programme in Zambia.

The engagement of WFP, an agency with strong logistics and transport knowledge obtained over many years when dealing with relief food to remote hard to reach areas, freed the malaria programme from complexities of commodity (LLIN) distribution and transportation responsibilities and challenges to concentrates on providing overall oversight. The WFP delivered LLINs from point of manufacturer in Tanzania to the health facility level. Government ministries including; the Ministry of Education, Ministry of Defense and the Ministry in charge of Community Development and local municipal authorities supplemented transport needs.

Local District administrators—such as the District Commissioners (DCs) supported district coordination meetings. The Churches Health Association, a Faith-Based Organizations (FBO) and World Vision International with vast experience in working with CHWs in rural, hard to reach communities worked with Community NHC structures to achieve “the last mile” distribution of LLLINs through the door-to-door LLINs delivery to beneficiaries. Community NHC structures were particularly critical in the final distribution of LLINs from Health facilities to end users; they supported correct LLIN use.

A total of 6,646,500 LLINs were procured for the mass distribution (Fig. 2). Of these 6.0 million were distributed through mass distribution to the beneficiaries, while the 646,500 (balance from the procurement) was kept to be used for routine distribution. The Global Fund against HIV/AIDS, tuberculosis and malaria procured 4,725,357 LLINs; the United States Presidents Malaria Initiative procured 1,627,357 LLINs; the Ministry of Health and NGOs contributed 16,673 and 277,113 respectively. With micro-plans developed and shared at all levels, implementation of the mass distribution campaign was smooth. In Zambia, the allocation of an LLIN to a household to achieve universal coverage with LLINs was based on delivering one LLIN per sleeping space in a given household; one net for every two people allocation was used in the previous year.

The majority (90%) of the LLINs were delivered to beneficiary households through the door-to-door method according to an approved distribution plan. By this method (i.e., door-to-door) a CHW directly delivered LLINs to recipients at their homes, hung the nets over each sleeping place for them and provided the beneficiaries with key messages and package of IEC for behaviour change and communication in the different provinces (Fig. 3) before leaving the households. Village-community registers were used for the distribution of LLIN to households. This provided a systematic way of distribution, thereby avoiding giving LLINs to persons who could have already received the nets. The distribution of LLINs to the remaining 10% of households was through—the “fixed point” distribution, another method where LLINs were delivered to the beneficiary at a selected, fixed point—usually a school or church premise in situations where heads of household (house owners) did not accept/allow entry of net distributors into their bedrooms or sleeping place areas due to cultural reasons.

Information, Education, Communication materials and health education were also provided at the “fixed point” distribution sites. The actual numbers of LLINs for distribution during the each of the two methods was guided by the district micro-plan, supported by national guidelines developed to support door-to-door and fixed point.

In Zambia, implementation of the mass LLINs distribution has been complemented by routine distribution through antenatal clinics (ANCs) to sustain achieved ownership and use by mass distributions (Figs. 2, 3 and 4). In 2007, a total of 248,655 LLINs were delivered through antenatal care clinics. The number increased to 885,500 in 2011 (about 25% compared mass distribution) but ANC distribution was reduced in 2014 to only 490,000 LLINs because of increased volume distributed through the mass campaign (Fig. 2). During the first National Malaria Strategic Plan in 2001–2005 school distribution was employed as a complimentary approach to service the school-going population but was discontinued in the NMSP 2006–2010 due to competing budget needs for integrated vector control in the country. An attempt to revive this is currently underway.

Community mobilization before, during and after the mass LLIN distribution campaign was mediated through the use of various channels that included interpersonal communication, mass and the print media. To assure quality, harmonization and coordination, key messages were developed by the national IEC Technical Working Group team of experts derived from several partner agencies and NGOs. This team developed a comprehensive IEC package containing, radio guides, scripts for radio stations, ITNs leaflets. The materials, which included brochures and fliers, were used to provide information on the planned mass campaign, solicit community participation and inform on the need for sustained use of LLINs.

It was observed that radio broadcasts on key ITN messages facilitated a highly valuable interaction between health workers staff and communities. The radio messages were produced both in English and local languages which was appreciated by communities. In the past 5 years several radio stations have been established in all the provinces at the district level in Zambia. Broadcast on local radio stations using “phone-in radio programmes” helped ITN district programme managers to respond to questions raised by communities on the distribution process on a real-time-basis and to remove any negative rumours. Broadcasts reinforced critical information on ITN use and care to strengthen general community awareness on malaria.

The NMCP delivered the health promotion messages and materials to Provincial Offices for final dissemination to communities. Training related to the IEC for behavioral change was integrated into the main LLINs cascade training to equip Community Health Workers on interpersonal communication skills, focusing on effective use of LLINs by householders. CHWs with support from area traditional leaders (chiefs) delivered key LLIN messages strategically identified periods or phases of the mass campaign, namely; before and during the mass campaign to inform communities on the value of participating in the mass campaign and the need for them to spear-head the education campaign, given their comparative advantage of living within the community and personal relationship with the beneficiaries. The CHWs also played the role of ensuring that the nets that were hung, were being utilized; they also answered any questions that beneficiaries raised.