Distributing Long Lasting Insecticide Treated Nets
Botswana: Malaria is one of the major public health problems in Botswana and is endemic in the northwest part of the country, mainly in five districts. According to the most recent Malaria Indicator Survey (MIS) in three of the Malaria endemic districts, 9.4% of households have at least one Insecticide Treated Net (ITN). Only 6.5% of children under five years of age and 3.8% of pregnant women used an Insecticide Treated Net (ITN) to protect themselves from Malaria. In response to this, Botswana has made the elimination of malaria a public health priority. A series of Long Lasting Insecticide Net (LLIN) education and distribution campaigns were organized in one of Botswana’s five endemic areas, the Okavango sub district.
The good practice reported here is an experience from the first large-scale campaigns between February and March 2009 organized in Okavango, one of the five endemic areas. The ownership of Long Lasting Insecticide Nets (LLIN) in Okavango increased from 12.6 % to 91 % after the intervention and the usage increased from 5.3% to 40% (MIS 2007; Okavango Pilot Evaluation Report 2009). The evidence-based Communication for Development (C4D) strategies were the driving force and an important factor for the successful Long Lasting Insecticide Net distribution campaign.
% of households owning at least 1 ITN
The free distribution of Long Lasting Insecticide Treated Nets to mothers and children was strongly linked to a C4D strategy which has been developed using findings from the 2007 Malaria Indicator Survey (MIS). The strategies also benefited from the inputs provided by the community stakeholders who participated in Triple A, a three step problem-solving process (Assess the problem, Analyze its causes and initiate Actions to improve the situation). The participatory process involved key stakeholders in an iterative cycle that repeats the problem-solving sequence leading to regular modifications and improvements in the approaches taken. The triple A process enables programme mangers to better tailor the intervention not only to the public health approach for malaria prevention but also to communities needs as of when and how to use the Insecticide Treated Nets.
The C4D strategy combined the following:
- Training of various key persons (distributors, supervisors, demonstrators, and follow-up teams) on Malaria and LLINs
- Mass distribution of Long Lasting Insecticide Treated Nets
- Interactive demonstrations on the utilization of Long Lasting Insecticide Treated Nets
- Monitoring of post-distribution was also conducted by the existing community structure i.e. the community health workers.
The C4D strategy particularly focused on the participatory aspect at the community level; performers did demonstrations in their own villages in local languages and demonstrations were highly interactive. Positive impact of the campaign has been reported from the follow-up survey in 2009 which compared the household data to the one from the Malaria Indicator Survey (MIS) in 2007.
Since 2009, this strategy has been expanded beyond the Okavango sub district up to the four other malaria endemic districts. To sustain the positive changes, the plan is underway to scale-up the pilot model including community involvement, sensitization and Long Lasting Insecticide Treated Nets free distribution by health workers targeting children and pregnant women, and a conduct of additional stand-alone campaigns in five remaining malaria endemic districts. This scale-up of distribution will be evaluated through a Malaria Indicator Survey (MIS) in 2011 and nets will be then made available to district health offices and health facilities.
Malaria is one the major public health problem in Botswana. Botswana is one of the six Southern African Development Community (SADC) countries set to achieve complete Malaria elimination by 2015. Malaria is particularly endemic in five districts in the northwest part of the country including: Okavango, Chobe, Ngamiland, Boteti and Tutume. Twenty Eight (28%) percent of the country population lives in these districts where over 80% of malaria transmission of the country occurs. In 2009 the malaria incident rate in the endemic areas was 27 cases per 1,000 population. (National Malaria Control Program, Ministry of Health).
According to the most recent Malaria Indicator Survey (MIS 2007) conducted in three of the Malaria endemic districts, 9.4% of households have at least one Insecticide Treated Nets which is significantly lower than the WHO-recommended level of 80% to achieve significant reduction of malaria transmission. Only 6.5% of children under five years of age and 3.8% of pregnant women use a net to protect themselves from Malaria. Anecdotal evidence suggests that in a few cases where nets are available to households they are used by adult family members for protection and other activities such as fishing. A triple exercise conducted in one of the endemic sites (Letlhakane) revealed shortage of nets and the price of P20.00 ($3.00) per net as reasons for low coverage of nets.
Health education follow-up visits and LLIN usage
The implementation strategy had several key components including:
Training of distributors and their supervisors
A 10-day training for distributors and supervisors was conducted. The training focused on knowledge on malaria and Long Lasting Insecticide Treated Nets, functionality of bednets, proper usage and care of bednets, distribution process and logistics, specific roles and responsibilities of team members, data recording, interpersonal communication skills and use of Geographic Positioning System (GPS) to map out households and areas where nets have been distributed. The distribution mode was pilot-tested in one village and modifications were made.
Training of community mobilization agents (demonstrators)
A group of 10 community-based drama performers selected from local drama groups were trained for two days. The content included basic knowledge on malaria including definition, causes, prevention, symptoms and detection of malaria. The training emphasized on the most vulnerable groups being children under 5 and pregnant women. The information was drawn from UNICEF’s Facts For Life and other locally produced information material. The performers came up with an interactive act that portrayed messages on basic knowledge about malaria as well as demonstrated the proper use and benefits of using Long Lasting Insecticide Treated Nets. Each village was to be covered by two performers.
Training of follow-up data
Health Education Assistants who are community health workers and members of the village health committees were trained on interpersonal communication and how to assess proper use of bednets using the house-to-house strategy. Their role is to check and assess knowledge and skills among the population and collect data on proper hanging, frequency of use and care of bednets.
The demonstrations which preceded a bed net distribution took place in 33 communities. They were meant to prepare communities for and sensitize them about the up-coming mass distribution. In each village, demonstrators performed at local primary school and during kgotla A kgotla is a public meeting where members of the community gathered to discuss matters of interest for the community. Consensual decisions usually come from those meetings. The village traditional leader also called the “kgosi” presides over the “kgotla”.
The presentations were interactive with performers engaging community members in a dialogue on issues related to malaria and benefits of using bednets. Community members actively participated in the demonstration; they came forth to feel and touch the net, hang it up and lie under it to have a feeling of the protective nature of the net. As a result, the community easily related themselves to the demonstrators, easily understood the messages and demonstrated eagerness to practice the new behavior once bed nets were distributed.
Mass distribution of Long Lasting Insecticide Nets
Mass distribution of Long Lasting Insecticide Nets followed soon after community demonstrations in each location. During distribution, each household was provided with a calendar with peak malaria months shaded in.
Follow-up on the use of Long Lasting Insecticide Nets
This activity is ongoing following the end of distribution between March and June 2009. It is done by Health Education Assistants and Village Health Committee members.
Partnerships, local structures, services and resources
This was a tripartite project funded by Ministry of Health, the Okavango sub-district, and the Clinton foundation who had acquired the LLINs through Malaria No More and UNICEF. Local structures involved in the project included traditional leaders, clinics and community health workers, as well as the Village Health Committees in each village.
Progress and results
The mass distribution of nets was completed at the end of March 2009 and a total of 33,000 nets were distributed in Okavango sub district. Each household was given bednets according to the number of sleeping spaces or the number of people living in the household, with the global assumption of one net for every two people.
A survey was conducted following distribution to gather data that could inform policy makers and future distribution methodologies for an Long Lasting Insecticide Treated Nets scale-up. A questionnaire based on the 2007 Malaria Indicator Survey was used to interview 557 randomly selected households throughout Okavango to assess coverage indicators (i.e. ownership and usage) and message retention. Key results from the evaluation report are below:
Ownership and usage of Long Lasting Insecticide Treated Nets (LLINs)
53,578 people (or approximately 91% of the total sub-district population) was covered by this distribution, including 8,937 children under five (16% of total population) and 845 pregnant women (1.5% of total population). The pilot project was successful in quickly scaling up Long Lasting Insecticide Nets ownership in Okavango from 12.6% of households owning at least one Insecticide Treated Net in 2007 to 91% owning at least one Insecticide Treated Net in 2009, over 90% of which were Long Lasting Insecticide Nets distributed in the pilot of surveyed households. Insecticide Treated Net usage also increased from 5.3% of Okavango women sleeping under a treated net in 2007 to 38.9% sleeping under a treated net in 2009.
As a follow up of the Okavango pilot in 2009, about 20,000 ITNs were also distributed in Ngamiland, another malaria endemic district. In 2010, the project has been scaled up to the five malaria endemic districts (Okavango, Ngamiland, Chobe, Boteti and Tutume) where 96,000 bednets have been distributed as of July 2010. Over the last two years, the project managed to distribute almost 150,000 bednets.
Costs by activity per LLIN
Social mobilization visits and posters
Logistical challenges and miscommunication prevented many health education assistants (HEAs) and village health committee (VHC) teams from starting their door-to-door follow-up campaigns. As a result, by the survey in May 2009, only 32.6% of households reported being visited by HEAs or VHC members to discuss Long Lasting Insecticide Treated Nets usage. Only 4.7% reported being visited more than once. However, while 58.9% of households with 0 visits used an Long Lasting Insecticide Treated Net, 63.1% of households that received 1 visit used an Long Lasting Insecticide Treated Nets and 68.5% of households that received less than one visit used an Long Lasting Insecticide Treated Nets. These differences are significant and indicate health education visits are associated with higher usage.
Also, logistical challenges hindered plans to distribute posters to every household in Okavango. Instead, the survey indicates that only 20% of interviewed households owned one of the posters designed for the pilot. These posters were supposed to be distributed during HEA/VHC visits to homes; however, there was no apparent correlation between poster ownership and visits, suggesting that many or most of the posters were distributed by other means, likely at the clinics themselves.
Despite these challenges, the sample size of households owning posters was large enough to analyze. Households with a visible poster were 26% more likely to use a Long Lasting Insecticide Treated Net than those either not displaying a poster or never having received a poster among those who did receive Long Lasting Insecticide Treated Nets. Households with a visible poster were also more likely to use an untreated net, an interesting association that implies further community education on the importance of a treated net, although the poster explicitly stated to use a net with insecticide. The difference between the use of non-pilot distributed nets and Insecticide Treated Nets and whether the household had a visible poster is small and not statistically significant.
The total expenditure for the Okavango Long Lasting Insecticide Treated Net pilot was $272,590, or $8.35 per Long Lasting Insecticide Treated Net distributed. Cost of consumables contributed to the majority of costs with personnel costs contributed 12% to overall expenditure. The nets themselves cost $5.65 (extra-large) and $4.89 (single). Training, transport and activities, such as poster design and printing, contributed the remaining 12% to total cost.
The costs of the distribution per person protected was $4.77 (population=57,146), or $1.59 annually for three years knowing the minimum lifetime of a Long Lasting Insecticide Treated Net is three to five years.
To ensure timely and continued provision of Insecticide Treated Nets as the implementation faced some shortages and a priority had to be given to villages known to be most affected by malaria. The Ministry of Health has been procuring its bednets with the support of other organizations.
To sustain the gains made by the project efforts to integrate the intervention within the health care system in five endemic districts must continue.