Challenges and Recommendations in Distribution of LLINs in Urban Contexts

by Brooke Farrenkopf

With the malaria team made up of public health nurses and an infectious disease specialist in Kumasi

I participated in a study on urban distribution of long lasting insecticide treated bednets (LLINs) as part of the USAID/PMI VectorWorks Project of the Johns Hopkins University Center for Communication Programs aided by a JHU Global Health Field Placement Scholarship. I conducted qualitative interviews to support a programmatic study on the challenges associated with mass distributions in urban contexts and helped develop report recommendations for developing the guidelines for future campaigns in urban areas. I am sharing my findings here.

As noted VectorWorks is funded by the US President’s Malaria Initiative and works to improve access to long-lasting insecticide treated nets (LLINs) in 12 countries in Asia and Africa. VectorWorks Ghana, through collaboration with the National Malaria Control Program (NMCP) and partners, supports the following distribution campaigns:

  • School-based distribution, occurring every May for grades 2 and 6
  • Continuous facility-based distribution at ANC and EPI visits
  • Point mass distribution campaigns, occurring every 3 years

In Kumasi, Takoradi, and Tamale, a point mass distribution campaign had already occurred. The campaign in Accra occurred while I was in Ghana, and I was able to visit the distribution sites and the health facilities where a portion of the LLINs were stored. Here, I was able to see some of the logistical challenges associated with the urban context.

I was also able to see the solutions put in place by the local malaria teams. One solution to improve program delivery was the development of a coupon coding system. As each community member attended the distribution site to receive a LLIN, Ghana Health Service (GHS) staff had to match their registration coupon with the coded coupon in the book. The coding system organized the coupons and identified members who had not attended distribution.

Mass distribution campaigns are the most effective method to rapidly increase long-lasting insecticidal net (LLIN) coverage.  Mass distribution in urban areas with characteristically large and heterogeneous populations of high population density comes with higher costs and difficult logistics. Many inhabitants are not indigenous to the area and are of varied religious, occupational, and socioeconomic backgrounds. Urban areas commonly have large mobile working class populations that are difficult to access. These characteristics are unique to urban areas and introduces the need for improved guidelines in urban areas.

VectorWorks Ghana Team

To date, the National malaria Control Program (NMCP) guidelines for point mass distribution in Ghana have made no distinction between urban and rural areas and have therefore not addressed these differences. This study intended to provide information to refine these guidelines.

Most interviews were conducted in hospitals and health facilities where the members of the malaria teams were located. The interviews were conducted in-person in the four largest metropolitan areas in Ghana: Kumasi, Greater Accra, Takoradi, and Tamale. I helped develop and follow a question guide that covered each phase of the distribution focusing on the challenges, solutions, and recommendations associated with each phase of distribution.

Most common challenges with implementation in urban communities:

  • Reaching community members during registration
  • Completing registration within the period of days provided and the volunteers allocated, because the population was too dense to reach all of the households and many community members were not at home during registration
  • Beneficiary dissatisfaction with universal health coverage definition of sufficient LLIN coverage {one net per two people in each household}

Most common recommendations for future distributions:

  • Greater inclusion of sub-metro teams in development of the micro plan
  • Increase the resources to recruit and remunerate more volunteers and supervisors to enable more distribution sites, help control crowds, and allow fewer days for each phase
  • Intensify social mobilization and allow sub-metros to help develop this plan to utilize local resources, especially to improve understanding of universal health coverage definition of one net per two people and to inform about logistics
  • Increase the number of registration days
  • Conduct a utilization study to understand coverage of LLIN use and barriers to  consistent use.

I was able to speak with public health nurses, malaria experts, and district health directors, and hear their insight on how to improve future campaigns. My favorite anecdotes included examples of how teams developed innovative solutions to improve campaign efficiency or strategically access hard to reach populations.

The observations and recommendations by the respondents themselves should guide future LLIN campaigns in urban settings in Ghana.

References

  • VectorWorks (2017) Johns Hopkins center for Communication Programs. http://ccp.jhu.edu/projects/malaria-vector-control/
  • de Beyl CZ, Koenker H, Acosta A, Onyefunafoa EO, Adegbe E, McCartney-Melstad A, Killian A (2016) Multi-country comparison of delivery strategues for mass campaigns to achieve universal coverage with insecticide-treated nets: what works best? Malaria Journal, 15(1): 1.
  • Stakeholder Review of Experiences in urban Long-Lasting Insecticidal Net (LLIN) campaign distributions (2012). Malaria Consortium Africa.

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