ALLOCATING LLINS DURING UNIVERSAL COVERAGE

1. ALLOCATING LLINS DURING UNIVERSAL COVERAGE Tim Freeman Project Manager - Rotarians Against Malaria – Papua New Guinea September 2010

2. WHO (World Health Organisation and RBM (Roll Back Malaria) partnership supported by Global Fund now recommend that countries protect everyone in malarial areas with Long Lasting Insecticidal Nets (LLINs). This is called Universal Access or Universal Coverage. In this way LLINs will protect whole populations in the same way as Indoor Residual Spraying (IRS). UNIVERSAL COVERAGE - ALLOCATING LLINS Universal Access

3. Giving access to LLINs to everyone in the population in an equitable manner. Once people have access getting them to use the nets every night! The first factor is primarily dependent on logistics and second mainly on social mobilisation. UNIVERSAL COVERAGE - ALLOCATING LLINS Two Challenges To Universal Access

4. Campaigns to children under five (17.5%) and distribution to pregnant women (5% per year) may cover 65% of the population over three years if we assume each net is used by 2 people. Two nets per family – Ethiopia, Nigeria, and Equatorial Guinea. Three nets per family – DRC. One net for every two people (no extra net for odd number families) – Lao One net for every two people (extra net for odd number families) – Burkina Faso Distribution based on sleeping patterns within families – Papua New Guinea and Mozambique UNIVERSAL COVERAGE - ALLOCATING LLINS Intervention Strategies

5. One off campaigns where LLINs are distributed by people being present – e.g. under fives campaigns where children have their fingers painted to avoid duplication of distribution. Options include: calling families together, people coming in pairs, distribute only to women assuming for every women is a man etc. Distribution against a list of beneficiaries. UNIVERSAL COVERAGE - ALLOCATING LLINS Distribution Mechanisms

6. Campaign distribution has huge problems of crowd control. Under five campaigns represent only 17.5% if the population so imagine crowd five times much larger. Campaign distribution means having huge logistic burdens that need to be prepared to happen within a very short time frame. Unless lists are already available, making lists presents huge practical problems. However distributing against reliable lists is considered the only way forward to do orderly and equitable mass distributions of LLINs. UNIVERSAL COVERAGE - ALLOCATING LLINS Challenges Of Distribution Mechanisms

7. Who Should Make Lists – Communities OR Others Communities – they know all their community members but on the negative side may not have experience or may decide to inflate figures to gain more nets. NGOs, Health Staff or other organisation – expensive, don’t know the communities in details and no guarantee they will do a good job. Trick therefore to use the community but find ways to ensure and verify that the lists produced are inclusive, accurate and verifiable. UNIVERSAL COVERAGE - ALLOCATING LLINS Who Should Make Lists

8. UNIVERSAL COVERAGE - ALLOCATING LLINS Making Lists – Who To Record • What type of list? Head of households OR all family members. • Experience from Zambezi Valley in Mozambique during the flood emergencies in 2007 and 2008 showed that when community leaders create lists based on only head of households, the leaders had problems defining what is a head of houses resulting in lists which were very unreliable. Similarly this type of list only allows distribution based on family unit. E.g. 2 nets per household. • Nigeria is making lists of head of household and number of people in each family. • Mozambique and Papua New Guinea it was decided to record everyone by name age and sex. It makes the creative reporting more difficult and lists more verifiable. Also if people don’t fully understand definition of a family this can be seen in the list and rectified later.

9. UNIVERSAL COVERAGE - ALLOCATING LLINS Verifying Lists • In Mozambique volunteers were asked to pin up lists of families on a public place so villagers could verify the lists made. • Alternative, as done in Papua New Guinea where survey books are used and these are not possible to pin up on walls, volunteers are asked to read the family members recorded to a public meeting. • In this way lists become transparent and community owned which is believed to make them more reliable.

10. One LLIN for mother, father and children under six. One net for boys over the age of six and over. One net for girls over the age of six or over. One extra net for any dependents e.g. grandparents, uncles etc. UNIVERSAL COVERAGE - ALLOCATING LLINS Distribution Strategy (Papua New Guinea)

11. One LLIN for mother, father and first child (if under three). One net for every three children One net for boys over age of ten One extra net for any dependents e.g. grandparents, uncles etc. Based on these criteria, village lists were reviewed prior to the distribution to decide how many nets each family would receive. In cases of where it was not clear, this could be discussed to come up with a joint decision. UNIVERSAL COVERAGE - ALLOCATING LLINS Distribution Strategy (Mozambique)

12. Villages informed some days in advance of distribution. Each family expected to send one representative. At time of distribution, crowd control is very orderly though in PNG sometimes it is necessary to call in the police to help. In Papua New Guinea and Mozambique LLINs were opened and coded before distribution to allow for later analysis and to discourage selling nets in the open market. UNIVERSAL COVERAGE - ALLOCATING LLINS Distribution

13. UNIVERSAL COVERAGE - ALLOCATING LLINS Distribution – Papua New Guinea

14. UNIVERSAL COVERAGE - ALLOCATING LLINS Distribution - Mozambique

15. The project in Papua New Guinea has distributed about 400,000 LLINs to date in five provinces. An analysis was made of 800 households to compare a needs based distribution against other types of net allocation. A similar exercise was done in Mozambique with 327 households. UNIVERSAL COVERAGE - ALLOCATING LLINS Results

16. UNIVERSAL COVERAGE - ALLOCATING LLINS

17. UNIVERSAL COVERAGE - ALLOCATING LLINS Results (3) Summary Of Results For Household Distribution In Papua new Guinea

18. UNIVERSAL COVERAGE - ALLOCATING LLINS Results (4)

19. UNIVERSAL COVERAGE - ALLOCATING LLINS Results (5) Summary Of Results For Household Distribution In Mozambique

20. Families or households as the case of Papua New Guinea and Mozambique each have difference needs depending on composition of age and sex of household members. Fixed allocations systems will always leave some families with too many nets and other families with not enough. UNIVERSAL COVERAGE - ALLOCATING LLINS Lessons Learned

21. Data collected from Mozambique and from Papua New Guinea suggests that distribution of nets based on need is the most equitable way of distributing nets to a population and at the same time needs less nets than other methodologies that give similar coverage but which always leave some families with too many nets and other families with too few. UNIVERSAL COVERAGE - ALLOCATING LLINS Conclusion

22. People need little encouragement to use LLINs when there are lots of mosquitoes. But to get people to use LLINs throughout the year every night is a huge challenge. To achieve this goal, people need to get a clear message from many sources. Social mobilisation needs to be done before, during and after the distribution and channels can include: National and community radio. Pamphlets, posters and billboards. Religious and political structures Schools, community based organisations and NGOs. One to one communication through activists, health workers and traditional healers. UNIVERSAL COVERAGE - ALLOCATING LLINS The Final Challenge

23. UNIVERSAL COVERAGE - ALLOCATING LLINS The Final Challenge (2) • The challenges are different in each country. • People in PNG don’t generally sleep outside so it is hot and stuffy in their houses to use nets. • People in Mozambique sleep outside during the hot season but as soon as it cools down they move inside and stop using their nets.

24. UNIVERSAL COVERAGE - ALLOCATING LLINS Thank You, Obrigado, Tenk Yu Tru Prepared By Tim Freeman, Rotarians Against Malaria, Papua New Guinea rampm@leasemaster.com.pg or malairzw@yahoo.co.uk