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Evaluation report

2013 Ghana: Evaluation of the LLIN Universal Mass Distribution "Hang-Up" Campaign in Brong Ahafo, Central and Western Regions of Ghana: Costs and Effects

Author: Lucy Paintain, Margaret Gyapong, Elizabeth Awini, Sheila Addei, Vida Kukula

Executive summary

"With the aim to continuously improve transparency and use of evaluation, UNICEF Evaluation Office manages the "Global Evaluation Reports Oversight System". Within this system, an external independent company reviews and rates all evaluation reports. Please ensure that you check the quality of this evaluation report, whether it is “Outstanding, Best Practice”, “Highly Satisfactory”, “Mostly Satisfactory” or “Unsatisfactory” before using it. You will find the link to the quality rating below, labelled as ‘Part 2’ of the report."


Between December 2010 and August 2012, approximately 12.8 million long-lasting insecticide-treated nets (LLINs) were distributed through a universal Hang-Up Campaign in all ten regions of Ghana. The campaign included pre-registration of sleeping places, distribution of LLINs through hang-up visits by volunteers and post-distribution "keep-up" behaviour change communication activities.


The aim of the evaluation was to assess the effectiveness and cost effectiveness of the long-lasting insecticide treated net (LLIN) Hang-Up campaign in Brong Ahafo, Central and Western regions of Ghana. Meanwhile, the objectives of the evaluation were: to assess the effectiveness of an LLIN Hang-Up Campaign on increasing household LLIN ownership; to assess the effectiveness of an LLIN Hang-Up Campaign on increasing and sustaining LLIN use by children under five years, pregnant women and total population; to define the costs associated with an LLIN Hang-Up Campaign and determine cost effectiveness; to model the potential added value of hang-up activities as part of an LLIN mass campaign and guide future decision making.


A mixed-methods approach was used to evaluate the Hang-Up Campaign in Brong Ahafo, Central and Western regions. Quantitative data on key net indicators was collected through a two-stage cluster household survey and compared to pre-campaign data from the 2011 MICS survey; qualitative data was collected through focus group discussions and in-depth interviews with key stakeholders involved in campaign implementation; and a full financial and economic cost and cost-effectiveness analysis was conducted. 

Findings and Conclusions:

Significant improvements were achieved in all three regions that can be attributed to the Hang-Up Campaign: household ownership of ITNs and use by all individuals, children under five years and pregnant women doubled between pre- and post-campaign household surveys.

Ghana Health Service targets for universal coverage were closer to being met in Brong Ahafo than Central or Western regions:

ITN use was 2-3 times higher in households with at least one ITN per two people and more households in Brong Ahafo owned at least one ITN per two people compared to Central and Western regions.

ITN use was 5 times higher in households where at least one ITN was observed hanging on the day of the survey.

Although the proportion of households that had all of their campaign nets hanged by the volunteer was consistent across the three regions at around forty percent, more households received nails and ropes to hang their own nets in Brong Ahafo and were more likely to have nets observed hanging on the day of the interview. This suggests that providing materials to hang the nets is very important to encourage hang up and use.

Having sufficient nets is not the only factor influencing use; there is also likely to be some influence of the level of existing net culture and ITN use may decline with time since distribution.

The universal campaign successfully increased ITN use by all individuals although not at the expense of use by children under five years which were still twice as likely as older children and 1.5 times as likely as adults to sleep under an ITN.

In terms of cost per LLIN delivered and cost per death averted, the Hang-Up Campaign compared favourably with previous mass campaigns and other LLIN distribution channels.

Evaluating full economic costs from the societal perspective confirmed the importance of the unpaid time that volunteers committed to the campaign.


Factors relating to campaign logistics and planning

Such large-scale and intensive campaigns require effective communication between all partners and well-coordinated logistics management. It is crucial that standard information is passed from the national to the regional to the district levels and ultimately to the community level.

A field guide to direct implementers at each level would be very useful to help make the campaign run more smoothly. The guide should incorporate lessons learnt from pilot campaigns and similar campaigns in other countries where relevant.

Assigning timelines for various aspects of the campaign should be scheduled in consultation with other health program managers to ensure that campaign activities do not coincide with other health programs such as national immunization days.

Set realistic timelines in consultation with Regional and District Health Authorities, allowing adequate time for campaign activities. Also ensure that measures are put in place so that schedule is adhered to.

Ensure that all needed resources and logistics needed for campaign are ready before the campaign activities start. This includes registration books, LLINs, non-LLIN materials (such as hammers, nails and ropes) and the means to transport the LLINs within districts or sub-districts such as wheel barrows and bicycles.

Ensure that gaps between different phases of the campaign activities are kept to a minimum e.g. between registration and hang-up.

Field monitoring and logistics management must be more effective to ensure that needed materials are moved appropriately and on time.

Education and announcements preceding such exercises should be more intense and over a longer period of time. Information given should be uniform and standard across all regions.

Criteria for allocating nets should be clear and understood by recipients and distributors.

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Report information






Ghana Health Service, DFID


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