Distributing Long Lasting Insecticide Treated Nets (LLINs) Ante-Natal Care (ANC) services reach mothers and children at-risk

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1 P R O M I S I N G A P P R O A C H E S The Health Marketing Initiative The AFFORD Initiative is a five year, USAID-funded program that uses innovative marketing approaches to improve Ugandans heath. The Initiative focuses on four areas: HIV/AIDS, malaria, family planning, and child health. AFFORD also expands markets for health products and services, improves product distribution, and encourages community action on health. Distributing Long Lasting Insecticide Treated Nets (LLINs) Ante-Natal Care (ANC) services reach mothers and children at-risk 1

2 DISTRIBUTING LONG LASTING INSECTICIDE TREATED NETS (LLINs) Distributing Long Lasting Insecticidal Nets (LLINs) Ante-Natal Care (ANC) services reach mothers and children at-risk According to Uganda s Ministry of Health, 300 people die each day from malaria, despite the fact that the disease can be simply and effectively prevented by using an insecticide treated mosquito net. Pregnant women and children under five years are highly vulnerable to malaria. The primary objective of net distribution through antenatal care services (ANC) is to protect pregnant women and breastfeeding mothers from infection, as well as to shield infants and young children from the disease. Actively promoted by Village Health Teams, access to free mosquito nets provides an additional incentive for pregnant women to seek antenatal care. Because Uganda has relatively high ANC attendance (above 80%), this approach reaches the majority of pregnant women. This mechanism also constitutes a keep up strategy, helping to ensure a regular flow of treated nets into the community, and maintaining satisfactory community coverage between free distributions. All government (and some non-governmental organizations, NGOs) health facilities across Northern Uganda providing antenatal services participate in this effort. During her first ANC visit, each pregnant woman receives a free net, and learns about its benefits, use and care. ANC distribution is conducted through the district health system with training, support and supervision from the Malaria Consortium. Key innovation LLINs have been shown to reduce malaria transmission and complications in both mother and child if used throughout pregnancy and for the first few months post partum. Ideally, all pregnant women should sleep under treated nets throughout pregnancy. The availability of free nets at ANC clinics encourages pregnant women to seek out antenatal care and related health services, including Intermittent Preventive Treatment in pregnancy (IPTp) for malaria. To deliver LLINs where they are needed most, AFFORD implemented four complementary mechanisms targeting those at higher risk of malaria pregnant women, children under five, and people living with HIV/AIDS: 1) Antenatal care clinics provide free nets to pregnant women. 2) Community-based campaigns reach pregnant women and children under five throughout entire districts. 3) The LLIN facility serves Civil Society and Non-Governmental Organizations with free nets. 4) Price subsidies for private sector distributors reduces the cost for the end consumer. This mixed model approach employed by AFFORD ensures rapid attainment of community coverage targets, while sustaining past distribution sites through routine distribution. This strategy achieves rapid scale up through campaigns and maintains net coverage through ANC distributions, 2

3 both supported by comprehensive behavior change communication encouraging net use. Why it works Net distribution in concert with behavior change messages increases proper use and net retention. Prior to beginning a distribution, AFFORD conducts health education sessions on the dangers of malaria, the benefits of LLINs, and proper net use. Field teams visit recipients in their homes to clarify myths and misconceptions regarding these nets. At the same time, AFFORD reinforces key messages through its other communication activities such as The Good Life Show. Utilizing existing networks makes for cost-effective distribution. To tap the largest possible distribution network, AFFORD partners with both government and Non- Governmental Organizations. Working with antenatal clinics in the government health system, AFFORD gains access to a widereaching delivery system. At the same time, collaboration with Community-Based Organizations enables AFFORD to reach people without access to health products and services. Public-private partnerships grant access to larger distribution networks. By offering price support to commercial distributors, AFFORD enables high-quality LLINs to compete with cheaper, less effective mosquito nets at comparable prices. Where we are now ANC distribution is in place across 24 districts, including all those in the Acholi, Lango, West Nile and Karamoja regions, as well as in three Teso districts. In total, over 430 health facilities are involved in the ANC distributions. Over 400,000 LLINs have been distributed through ANC since the activity began. Beneficiaries have consistently demonstrated high net use and retention. A recent retention survey in Gulu district analyzed 279 questionnaires from four health facilities and found: 1) Net retention 99.3% 2) Use of ANC 88.6% 3) Use of ITN by beneficiary 96.3% These data reflect significant increases in use and retention over previous surveys. ANC attendance two years prior to LLIN distribution and during the distribution period shows 3

4 DISTRIBUTING LONG LASTING INSECTICIDE TREATED NETS (LLINs) marked increases. Over 95,000 new women were registered in the last quarter alone, and the number of new ANC attendees each month continued to grow incrementally. How we did it AFFORD began by informing District Health Teams about the activity, and then training health workers in benefiting districts and health facilities on net distribution, community education and data recording. The program provided data collection tools and communication materials for distribution through local health facilities. Malaria Consortium delivered nets to the districts, and then using a pool system, delivered them directly to health facility or sub-district stores. While districts are responsible for support supervision to the health facilities, the Malaria Consortium routinely provides external support supervision and refresher trainings to all district and health facility staff involved in the distributions. Together with the district and community health team, Malaria Consortium also conducted net retention and use surveys in various locations. After the results were reviewed, the Malaria Consortium revised its strategies in collaboration with the district health teams. Challenges Inefficiencies in the Health Management Information System (HMIS) can make data collection difficult and hamper program tracking. District delays in accounting for funds can lead to further delays in the release of funds for later net deliveries and district support supervision. Frequent changes in health facility staff create a continuous need for training. Despite security and tracking systems, some leakages from the district stores persist. Security concerns have hampered some distributions, particularly in the Karamoja region. Low educational attainment among community-based implementers and weak district data collection systems can compromise monitoring data s quality and timeliness; and Community-based net distribution involves operational risks such as the transportation of large amounts of cash and keeping nets in district-level storage. What we have learned Distribution of free LLINs through ANC has resulted in increased ANC attendance at participating health facilities. 4

5 It is important that district health teams conduct routine support supervision at health facilities. For quality assurance reasons, however it is also necessary for AFFORD to conduct external support supervision, regular on the job training, and sometimes to directly support data collection. There is a need to harmonize the data collection and support supervision tools used by AFFORD had to be harmoized with those already used by the HMIS system. Where tools must differ from the HMIS, it is important that districts are involved in their development and testing. Ongoing availability of LLINs is critical for several reasons: first, to ensure that the demand from pregnant women is met early in pregnancy, and second to avoid net stock-piling after a stock-out. Heightened demand for nets after a shortage increases chances of repeated shortages. Second, the lack of nets during ANC visits can hurt the quality of educational activities. Third, some pregnant women will be unable to make an additional return visit to collect their free net. Community-based implementers require rigorous training and supervision to improve data collection. Transferring program funds directly to districts bank branches eliminates the risk of transporting large amounts of cash. Hiring private stores with guards discourages the theft of nets. Removing nets from their plastic bags reduces resale value and discourages beneficiaries from selling them; and, Hiring temporary assistants to collect data from ANC health facilities that distribute nets improves data quality. What s next Going forward, it is critical that funding is available to meet the ongoing demand from pregnant women in districts where the activity has been taking place. The introduction of ANC distribution in additional districts should also be explored. AFFORD will continue to work with the National Malaria Control Program to further harmonize data collection and to support development of supervision tools for the project and HMIS, in particular to include data on the number of LLINs distributed to ANC as an HMIS indicator. Incentives are needed to encourage timely and quality data collection by district health teams. A survey methodology should also be developed to accurately track this distribution of nets from source to beneficiary. This will facilitate more effective monitoring and identify leakages in the distribution system. The study can also draw on tracking data collected throughout the project. The AFFORD Consortium The Johns Hopkins Bloomberg School of Public Health Center for Communication Programs Aclaim Africa Ltd. Communication for Development Foundation Uganda Futures Group International Malaria Consortium PULSE Communication Ltd. 5