Report on the Mass Distribution of LLINin Four Districts of Eastern Uganda, September2012
TABLE OF CONTENTS
LIST OF TABLES
LIST OF FIGURES
LIST OF ANNEXES
ACRONYMS
EXECUTIVE SUMMARY
BACKGROUND
GOAL and OBJECTIVES
PLANNING AND COORDINATION
Development of plan of action: Macro Planning
Pre- Visits to Districts (Micro Planning)
IMPLEMENTATION
Orientation and Training of Central Team
District Launch
Sensitization and Training at District, Sub-county and Parish Levels
Training of Village Health Teams and Village Leaders
Household Registration
Retrieval, Compilation and Validation of Data
Allocation Criteria of LLIN to Households
Distribution to Beneficiaries
LLIN LOGISTICS DISTRIBUTION
Allocation to Districts
Delivery to Districts
Transportation to Distribution Points
Transportation of LLIN to Island Areas
Logistics Risk Management
MONITORING, SUPERVISION & EVALUATION
COMMUNICATION
BUDGET / FINANCE
Reporting
CONCLUSIONS, RECOMMENDATIONS AND KEY LESSONS LEARNED
LIST OF TABLES
Table 1: Activity Schedule......
Table 2: District 2012 Population Projections and Political Structures (UBOS)......
Table 3: The Outcome of the Campaign Sensitizations across the Four Districts......
Table 4: The Outcomes of the Training across the Four Districts......
Table 5: Registration Outcomes (Number and Proportion)......
Table 6: Comparison between Projected and Actual Registration Outcomes......
Table 7: LLIN Dispatch Plan to District Stores......
Table 8: Distribution of Distribution Points (DPs)......
Table 9: Monitoring and Evaluation Indicator Framework......
Table 10: District Distribution Outcomes......
Table 11: Overall Campaign Coverage......
Table 12: Actual Spend versus Obligated Spend......
LIST OF FIGURES
Figure 1: Comparison of Household Sizes across the Four Districts
Figure 2: Comparison between Projected Population and Registered Population
Figure 3: Net Allocation to Beneficiaries in the Four Districts
LIST OF ANNEXES
Annex 1: Concept note for 650,000 LLIN
Annex 2: Implementation Guidelines
Annex 3: Training manual
Annex 4: Data collection tools
Annex 5: Validation tool
ACRONYMS
AMPAlliance for Malaria Prevention
ANCAntenatal Care
BCC Behaviour Change Communication
CAOChief Administrative Officer
CDCCenters for Disease Control
CSOCivil Society Organization
DHEDistrict Health Educator
DHO District Health Officer
DHT District Health Team
DP Distribution Point
GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria
HHHousehold
IECInformation Education and Communication
ITN Insecticide Treated Net
LC1 Local Council One (village chief)
LLINLong Lasting Insecticidal Net
MCMalaria Consortium
MFPMalaria Focal Person
MISMalaria Indicator Survey
MoH Ministry of Health
MPMember of Parliament
NCCNational Coordination Committee
NDA National Drug Authority
NMCP National Malaria Control Programme
PMI U.S. President's Malaria Initiative
PW Pregnant women
RDCResident District Commissioner
RBM Roll Back Malaria
SCSub-county
SMP Stop Malaria Project
TATechnical Assistance
TOT Trainer of Trainers
U5 Children under five years of age
UC Universal Coverage
UBOS Uganda Bureau of Statistics
UDHSUganda Demographic Health Survey
UNBS Uganda National Bureau of Standards
USAIDUnited States Agency for International Development
VHT Village Health Team
EXECUTIVE SUMMARY
In 2007, the Uganda Ministry of Health was awarded a grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM); to provide 17,666,984 long-lasting insecticidal nets (LLIN) to pregnant women and children below five years of age. In 2009, the Ministry of Health (MOH), in agreement with GFATM, reprogrammed this grant to provide two, large-scale campaigns.The first tranche (Phase I) of 7,295,850 LLINwere targetedfor pregnant women (PW) and children under five (U5).The second (Phase II) of 10,371,134 LLIN would be a fill-in campaign for Phase I, to reach universal coverage (defined as one net per two people). According to the Phase II distribution plan, the total LLIN need was 10,985,200. However, GFATM would only provide 10,371,134 LLIN as the balance after Phase I. The gap of 614,066 nets would be covered by an estimated 650,000 nets provided by PMI. The decision by PMI to provide 650,000 LLIN was based on the LLIN gap (649,162) for 33 sub-counties that missed LLIN in Phase I. This was in anticipation that Phase II would be conducted within one year from 2010, when Phase 1 nets were distributed. Unfortunately, the Phase II distribution did not take place as had been planned. Instead, it was decided to distribute the PMI nets in 2012, in order to inform the Phase II distribution which was rescheduled for 2013.
The goal of this activity was to attain universal coverage of LLIN in fourdistricts which did not receive LLIN under Phase I, and to use the distribution process to learn lessons to inform GFATM Phase II LLIN distribution.
The following criteria were established to select four of the seven districts in Eastern Uganda districts that missed LLIN distribution in Phase I, yet had been targeted; i) proximity of the districts to a lake or large water body; ii) total district LLIN need fit in the available LLIN; iii) district has not had any mass LLIN distribution since GFATM Round 2 Phase I (an indication of the absence of valid LLIN). Based on the above criteria, the four districts selected were: Bugiri, Kaliro, Serere and Mayuge.
The objectives of the activity were as follows:
- To increase the proportion of the households receiving at least two LLIN to 80% in the four districts by end of September 2012(as per the targetset at concept note development, see Annex 1).
- To test a practical method of validating registration data that can be adopted for future LLIN distribution campaigns.
- To determine the best stages of the campaign to intensify advocacy and social mobilization efforts.
A total of 329,558 households were registered across the four districts: 1,619,227 people were registered of whom 418,634 were children under five years and 56,431 were pregnant women. All registered households (HH) received at least one net and a maximum of 3 nets. A total of 651,860 LLIN were distributed amongst the registered HH reaching 1,619,227 people in the four districts. However, the goal ofthe activity, reaching universal coverage (one net per two people), was not achieved due to insufficient nets.
In respect to fulfilment of objective 1, the total number of HH that received at least two LLIN was 217,610 out of 329,558 registered HH, representing 66% achievement against a targeted 80% with a variance of 14%.
For objective 2, household registration data validation was done by benchmarking UDHS population size guidelines. The toolkit used to validate the compiled data included the following proportions: population that is pregnant was 5%;population under five years of age was 25%;average number of people per household was 6. All data retrieved and compiled was validated using this toolkit, thereby improving accuracy due to the inbuilt self-check mechanism. This enabled the validation teams to double check households whose statistics fell outside these demographic brackets. Field teams revisitedthese households to verify the HH information. Consequently, this improved the accuracy during allocation.
In view of objective 3, it was noted that continuous communication is an integral activity before, during, and after net distribution. This was realised through engagement of national leaders, filmvan mobilisation activities, training and involvement of village health teams (VHTs) and radio support activities.
A critical lesson learned was that in order to ensure universal coverage, sufficient stocks of LLIN should be secured based on an adjusted increment of 16% on UBOS data projections.
BACKGROUND
According to the Uganda Malaria Indicator Survey of 2009, 47% of households own an insecticide treated net (ITN).This is a significant increase from the 17% measured in the Uganda Demographic and Health Survey (UDHS) in 2006. In 2010, 7.2 million long lasting insecticidal nets (LLIN)were obtained and distributed with support from the Global Fund to Fight AIDS, TB and Malaria (GFATM) Round 7, Phase I. These nets contributed to an estimated household ITN ownership coverage of 74% (UDHS 2011). The Uganda National Malaria Control Program (NMCP) declared universal coverage of the entire population at risk of malaria as the strategic approach to LLIN distribution in 2010. However, on the advice of the GFTAM, the 2010 distribution targeted pregnant women and children under five. Nonetheless, household registration during these distributions included all families, irrespective of whether they included any members of the target group. This was done in 685 out of the then 964 sub-counties in Uganda, with the aim of recording the required number of long-lasting insecticide treated nets (LLIN) for subsequent distribution during Round 7, Phase II. Unfortunately, the Phase II LLIN distribution did not take place as had been planned (within one year of Phase I). Of the 685 sub-counties, 33 sub-counties (selected sub-counties in seven districts in the East) conducted registration but did not receive LLIN due to inadequate nets. Except Kaliro District, where all five sub-counties had registrations done, the other six eastern districts had sub-counties where neither registration not LLIN distribution was conducted. It is also known that in districts where distribution was conducted, not all sub-counties were covered.
Uganda is now preparing for Round 7, Phase II LLIN distribution, which is planned to begin in 2013. According to the Phase II distribution plan, the total anticipated LLIN need had been 10,985,200. It was expected that, GFATM would only be providing 10,371,134 LLIN in the Phase II grantleaving a gap of 614,066. The gap of 614,066nets was therefore covered by theU.S. President's Malaria Initiative (PMI), through a contribution of an estimated 650,000 LLIN. The PMI funded Stop Malaria Project (SMP) was assigned to provide technical and financial assistance to distribute LLIN in four districts to achieve universal coverage. As part of the technical assistance provided to NMCP, two people were also identified to provide technical support at the central and district levels for both the eastern distribution and GFATM Round 7 Phase II LLIN distribution.
As the concept development for the estimated 650,000 nets advanced and preparations for implementation were due, there was a turning point in the planning for Phase II. A visit from the Alliance for Malaria Prevention (AMP) mission to Uganda conducted between 24 June and 7 July 2012 recommended a new look at universal coverage (UC) in the country considering the period of over two years that elapsed between the Phase I and II distribution campaigns. As a result of the recommendations from this mission, Uganda’s National Coordination Committee (NCC) unanimously agreed to shift from using the Round 7 Phase I registration data to conducting fresh registrations,In addition, the 7.2 million LLIN distributed under Phase Iwere deemed invalid, since by the time of Phase II distributions in 2013, it would have been three years (the expected life of an LLIN) since the Phase I nets were distributed. Discounting all Phase ILLINmeant that Uganda’s actual LLIN need increased from the initially estimated 10.9million LLIN to 19.9million.
Based on these recommendations, it was decided that the distribution of LLIN in the four eastern districts be based on new household registration. During this distribution campaign, an effort would be made to provide practical solutions to challenges experienced in Phase I.Lessons learnt in the four districts will then inform GFATM Phase II distribution across the country.
GOAL and OBJECTIVES
Goal
To attain universal coverage of LLIN in the four districts and to use the distribution process to learn lessons toinform GFATM Round 7, Phase II LLIN distribution.
Objectives
- To increase the proportion of the households receiving at least two LLIN to 80% in the four districts by end of September 2012 (as per the target set at concept note development, see Annex 1).
- To test a practical method of validating registration data that can be adopted for future LLIN distribution campaigns.
- To determine the best stages of the campaign to intensify advocacy and social mobilization efforts.
Selection of Districts for Universal LLIN Distribution with PMI LLIN
The following criteria were established to select four of the seven Eastern districts that missed nets in Phase I but had been targeted:
- Proximity of the districts to a lake or large water body
- Total district LLIN need fit in the available LLIN
- District has not had any mass LLIN distribution since GFATM Round 2 Phase I (an indication of the absence of valid LLIN)
Based on the above criteria, the four districts selected were: Bugiri, Kaliro, Serere and Mayuge.
PLANNING AND COORDINATION
Development of plan of action: Macro Planning
A National Coordination Committee (NCC) led by NMCP was constituted including SMP,Malaria Consortium (MC), andother technical advisors jointly identified during a planning meeting held at NMCP. The core role of the NCCwas to support the entire campaign period and to monitor all stages of the activity. The NCC was supported by the two Technical Assistants (TA), for the central and district levels respectively.
Key accomplishments of the NCC included the following:
- Identification and recruitment of two Technical Assistants (at Central and District levels) according to Scopes of Work developed by the committee
- Development of the concept note, plan of action and budgets
- Identification of three taskforces that served as the technical/operations, logistics and communication sub committees
- Establishment of the campaign timeline, in coordination with SMP, MOH/NMCP and PMI
- Determination of the campaign results and preparation of the final campaign report highlighting key lessons learnt
The campaign implementation processes (pre, during and post campaign activities) remained as planned for Phase II. Prior tostarting the district level activities, there was orientation of central trainers and supervisors in Kampala. This was followed by a launch of the distribution exercise held in Kamuli district presided over by the Ho. Speaker of Parliament.
Below is a planned activity schedule that spelt out a uniformed implementation plan across the four districts.
Table1: Activity Schedule
Day / Planned Date / ActivityDay 1 / August 28, 2012 / Central Trainers/Supervisors travel to district
Day 2 / August 29, 2012 / Introduce Activity and partners to District Health Team and mobilize for district sensitization and training.
Day 3 / August 30, 2012 / Sensitize district leadership
Day 4 / August 31, 2012 / Training of trainers at district level
Day 5 / September 1, 2012 / Mobilization for sub-countysensitization
Day 6 / September 2, 2012 / Sub-county sensitization meetings
Day 7 / September 3, 2012 / Mobilization for parish leader sensitization / VHT training
Day 8 / September 4, 2012 / Parish leader sensitization and VHT training
Day 9 / September 5, 2012 / Household registration
Day 10 / September 6, 2012 / Household registration
Day 11 / September 7, 2012 / Retrieval of household registration data from VHTs
Day 12 / September 8, 2012 / Compilation of data
Day 13 / September 9, 2012 / Validation of compiled data
Day 14 / September 10, 2012 / Allocation of LLIN to households
Day 15 / September 11, 2012 / Allocation of LLIN to households
Day 16 / September 12, 2012 / Finalize allocation and inform central logistics
Day 17 / September 13, 2012 / Delivery of LLIN to district stores
Day 18 / September 14, 2012 / Distribution to beneficiaries
Day 19 / September 15, 2012 / Report writing
Day 20 / September 16, 2012 / Debriefing districts’ leadership
Day 21 / September 17, 2012 / Central trainers travel back to Kampala from the field
Pre- Visits to Districts (Micro Planning)
Integrated teams from NMCP and SMP/Malaria Consortium made pre-implementation visits to each of the four districts approximately two months before the actual implementation. The objectivesof the visits were to introduce the project to the district leadership and the district health teams (DHT), and to discuss key issues on district population and household (HH)dataand storagefacilities relevant to micro-planning. At the introductory meetings held at the district health offices the teams drew schedules for visits to sub-counties to gather current planning statistics so as to compare with thedata from the Uganda Bureau of Statistics (UBOS) and District Planners’ data. The teams worked with the Malaria Focal Person (MFP) or another member of the DHT delegated by the District Health Officer (DHO) to visit every sub-county (SC) to compile the necessary population data. Below is a table with the population projections and the administrative structural units at the different levels based on 2012 UBOS population projections.
Table 2: District 2012 Population Projections and Political Structures(UBOS)
District / # S/Cs / # Parishes / # Villages / #U5s / #PW / 2012 Pop.Mayuge / 13 / 74 / 513 / 93,188 / 23,066 / 461,329
Kaliro / 6 / 36 / 384 / 43,340 / 10,835 / 216,700
Bugiri / 11 / 62 / 364 / 87,508 / 21,340 / 426,800
Serere / 10 / 48 / 232 / 73,525 / 14,705 / 294,100
Total / 40 / 220 / 1493 / 297,561 / 69,946 / 1,398,929
Lessons Learned / Recommendations
- The districts appreciated the MOH and partners for contacting and involving them in all the phases of the process, including the planning phase. This enhances district ownership and involvement in the campaign. They suggested more involvement in the budgeting process as well.
IMPLEMENTATION
Orientation and Training of Central Team
Orientation of the central teams was a one day activity that took place on Wednesday 22August,2012 at Hotel Africana in Kampala. Theobjective of the training was to ensure that the central trainers understood the training manual and agreed on the plan of action for implementation. The sessions were facilitated by experienced trainers from NMCP and SMP/MC with the support of both the Central and District level Technical Assistants (TAs). A total of 55 participants attended including 43 civil society organization (CSO)sub-county supervisors, 4 CSO district supervisors, 4 MOH district supervisors and 4 Advocacy /BCC district supervisors. Approximately 65% (32)had previously participated in implementation of similar activities (GFATM Round 7 PH I) which gave a blend of experience and new perspectives within the team.
Lessons Learned / Recommendations
- The training focused a lot on the technical / operation guidance for implementation. There was little emphasis on some critical aspects like management of funds. The training should have clearly outlined and addressed key issues like budget and payment rates for specific activities. A two daycentral level training would be recommended; Day 1 to review the operations manual, M&E tools, and reporting;and Day 2 for finance & logistics training. Topics on Day 2 should include what rates to pay who for what, accountability procedures, quantification of field logistical resources required,e.g. stationery, folders, ropes, fuel, BCC materials, demo nets, etc.
- Developmentof district teams should be done in this forum to clarify the respective district and sub-county supervisors. A list of key contacts should be shared at this meeting as well (DHTs, MFPs, central coordinators, etc.).
- A list of frequently asked questions should be generated before the training and reviewed and added to at this training, with suggested best responses to ensure consistence in the lower trainings. This will also help to bring on board the newly recruited trainers (first timers) more quickly.
- A sample of the net to be distributed should be used in a demo session during this forum.
- A short pre and post test should be conducted before and at the end of the training as a means of evaluation of the sessions / training.
- Certificates of attendance can be awarded at the end of the training. Also a certificate of appreciation should be awarded to implementing teams at the end of the campaign considering the hectic period gone through during implementation.