ALLOCATING LLINS DURING UNIVERSAL COVERAGE Tim Freeman Project

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ALLOCATING LLINS DURING UNIVERSAL COVERAGE Tim Freeman Project Powered By Docstoc
					ALLOCATING LLINS
DURING UNIVERSAL
   COVERAGE


                      Tim Freeman
Project Manager - Rotarians Against Malaria – Papua New Guinea
                      September 2010
           Universal Access
• 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).
           Two Challenges To
            Universal Access

1. Giving access to LLINs to everyone in
   the population in an equitable manner.
2. 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.
    Intervention Strategies
1. 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.
2. Two nets per family – Ethiopia, Nigeria, and
   Equatorial Guinea.
3. Three nets per family – DRC.
4. One net for every two people (no extra net for odd
   number families) – Lao
5. One net for every two people (extra net for odd
   number families) – Burkina Faso
6. Distribution based on sleeping patterns within
   families – Papua New Guinea and Mozambique
       Distribution Mechanisms
1. 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.
2. Distribution against a list of beneficiaries.
    Challenges Of Distribution
          Mechanisms
–   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.
   Who Should Make Lists
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.
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.
                 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.
        Distribution Strategy
          (Papua New Guinea)
1. One LLIN for mother, father and children under
   six.
2. One net for boys over the age of six and over.
3. One net for girls over the age of six or over.
4. One extra net for any dependents e.g.
   grandparents, uncles etc.
        Distribution Strategy
                (Mozambique)
1. One LLIN for mother, father and first child (if
   under three).
2. One net for every three children
3. One net for boys over age of ten
4. 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.
                Distribution
•   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.
Distribution – Papua New Guinea
Distribution - Mozambique
                 Results
•   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.
                   NETS DISTRIBUTED AT HOUSEHOLD LEVEL IN PAPUA NEW GUINEA

                     Number Of Nets Given Per Family                                  Nets Allocated In Each Type Of Distribution

                                                                                                              1 Net       1 Net
                                                                                                              Per 2       Per 2
                                                                                                             People -    People
                                                                                                              1 Net      +1 Net
              1      2     3     4    5    6    7   9   10   12
Number                                                                                                       For Odd    For Odd
In                                                                                    Needs     2 Nets       Number     Number     3 Per
Househo                                                                    Number     System     Per           ed          ed       Nets
ld                                                                Total   In Family    PNG      Family       Families   Families   Family

        1    38                                                     38          38        38        38            38         38        38

        2    39     17                                              56         112        73       112            56         56       112

        3    18     46    17                                        81         243       161       162            81        162       243

        4    16     70    20     2                                 108         432       224       216           216        216       324

        5           47    56          1                            104         520       267       208           208        312       312

        6           18    81    23    1                            123         738       376       246           369        369       369

        7            2    52    32    5                             91         637       313       182           273        364       273

        8                 18    53    7    2                        80         640       313       160           320        320       240

        9                  6    19    15   1                        41         369       175        82           164        205       123

        10                       9    13   2    1                   25         250       120        50           125        125        75

        11                       3    10   1                        14         154        68        28            70         84        42

        12                       1    6    5    1                   13         156        71        26            78         78        39

        13                       1    1    7    1                   10         130        58        20            60         70        30

        14                                 3                         3          42        18             6        21         21         9

        15                                 1    1                    2          30        13             4        14         16         6

        16                                 1    3                    4          64        27             8        32         32        12

        17                                 3                         3          51        18             6        24         27         9

        20                                      1   1                2          40        16             4        20         20         6

        23                                              1    1       2          46        22             4        22         24         6

Total        111    200   250   143   59   26   8   1   1    1     800       4,692      2,371     1,562        2,191      2,539     2,268
                                  Results (3)
       Summary Of Results For Household
        Distribution In Papua new Guinea

                                                             1 Net Per    1 Net Per
                                                             2 People -    2 People
                                                             1 Net For    +1 Net For
                                           Needs    2 Nets      Odd          Odd       3 Per
                                           System    Per     Numbered     Numbered      Nets
FAMILY DATA                                 PNG     Family    Families     Families    Family

% Families With Too Many Nets                 0.0      9.1        12.0          31.1     32.0

% Families With The Right Number Of Nets      0.0     29.8        56.6          56.4     44.5

% Families With Two Few Nets                  0.0     61.1        31.4          12.5     23.5

Nets Needed Per 100 People                   50.5     33.3        46.7          54.1     48.3
                                    Results (4)
                       NETS DISTRIBUTED AT HOUSEHOLD LEVEL IN MOZAMBIQUE

             Number Of Nets                                                     Nets Allocated In Each Type Of Distribution
             Distributed


                                                                                                   1 Net Per 2   1 Net Per 2
                                                                                                    People -1     People +1
Number of                                                                  Needs                   Net For Odd   Net For Odd
people in                                                Number In         System     2 Nets Per    Numbered      Numbered     3 Per Nets
family           1        2    3    4    5   Total       Family          Mozambique     Family       Families      Families      Family

        1        8        0    0    0    0           8               8           8             8            8             8            8
        2       41       14    0    0    0       55            110              69          110            55            55         110
        3       14       38   12    0    0       64            192             126          128            64          128          192
        4        0       42   13    1    0       56            224             127          112          112           112          168
        5        0       17   25    4    0       46            230             125           92            92          138          138
        6        0        7   32    4    0       43            258             126           86          129           129          129
        7        0        0   14    7    0       21            147              70           42            63            84           63
        8        0        0    9    11   0       20            160              71           40            80            80           60
        9        0        0    5    1    0           6           54             19           12            24            30           18
        10       0        0    0    1    2           3           30             14             6           15            15            9
        11       0        0    0    1    4           5           55             24           10            25            30           15
Total           63      118   110   30   6      327           1468             779          646          667           809          910
                                Results (5)
          Summary Of Results For Household
             Distribution In Mozambique
                                                                            1 Net
                                                                            Per 2
                                                             1 Net Per     People
                                                             2 People -    +1 Net
                                                             1 Net For    For Odd
                                           Needs    2 Nets      Odd       Numbere    3 Per
                                           System    Per     Numbered         d       Nets
FAMILY DATA                                 PNG     Family    Families    Families   Family
% Families With Too Many Nets                 0.0     16.8         11.3       22.3     51.1
% Families With The Right Number Of Nets      0.0     38.5        56.9        63.0     37.9
% Families With Two Few Nets                  0.0     44.6        31.8        14.7     11.0
Nets Needed Per 100 People                   53.1     44.0        45.4        55.1     62.0
           Lessons Learned

• 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.
               Conclusion
•   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.
              The Final Challenge
•       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.
      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.
          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

				
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