Acknowledgements
This report is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of USAID/JHU Cooperative Agreement No. GHS-A‐00‐09-00014-00. The contents are the responsibility of Mohamad Sy-ar, Ato Selbi, Andrea Brown and Mamadou Diallo and do not necessarily reflect the views of USAID or the United States Government.
Trip Summary
Name of Travelers: Andrea Brown, Ato Richmond Selby, Mamadou Diallo and Mohamad Sy-ar
Country Visited: Madagascar
Dates of Travel: March 12 – April 05, 2013
Scope of Work
The purpose of the trip was to introduce the concepts and tools for planning and design of Continuous Distribution of LLIN to the Madagascar Roll Back Malaria partners and to conduct district-level situation analysis of options for continuous distribution to support the development of a pilot continuous distribution strategy.
Background and highlights
USAID/PMI Madagascar has asked NetWorks to assist with the design on an LLIN continuous distribution scheme to achieve and sustain national targets for LLIN coverage. Following the Madagascar USAID/PMI’s approval of their workplan at the end of February 2013, NetWorks fielded four (4) of its team members to Madagascar to conduct the following tasks: (1) to introduce the concepts and tools for planning and design of continuous distribution of LLIN and to train the RBM partners on the use of these tools through the NetCALC workshop, and (2) to conduct a field situational assessment of options for continuous distribution to support the design of a CD strategy. The NetCALC workshop took place at the Catholic Relief Services’ office on March 14, 2013 and attended by 25 participants. This workshop was followed by further discussions and meetings with the PMI and the NMCP team to ensure the outcome of the workshop was in line with the Madagascar’s malaria program as well as to prepare the team’s field activities.
Overall, the objective of the workshop was achieved. Here are the main highlights from the one day workshop:
1. Madagascar was the first country to field-test the NetCALC French version. There were a few minor errors that were discovered that will be corrected in the tool.
2. The workshop was attended by 25 RBM partners including two PMI staff. Due to political restrictions, no National Malaria Control Program (NMCP) or other government staff participated in this workshop.
3. The Consensus Statement by Roll Back Malaria, the Guide to Continuous Distribution and the Country-to-Country Guide to ANC and EPI were presented to participants. The rationale for LLIN continuous distribution was well understood and accepted by all participants.
4. Other relevant continuous distribution experiences from other countries were also shared with the participants to support a national-level modeling exercise of potential distribution channels and their impact on Malagasy household LLIN coverage.
5. To reach and maintain Madagascar’s goal of sustaining 90% coverage, it was decided that three channels of distribution will be examined in the field to see which one would be the most appropriate for the country and the sub-populations groups. These three channels included: (1) community based distribution through community health volunteers (Agent Communautaires) and social marketing; (2) health facility distribution through ANC&EPI and school based distribution through two classes in primary school (1st and 4th graders). Note that this decision was made under the assumption that if international aide restrictions were lifted.
6. The NetCALC tool was used to help participants simulate the different scenarios using different channels of distribution and to learn how they can contribute to improving and sustaining LLIN coverage. Simulation exercise was based on 92 districts, epidemic-prone areas and the areas of primary focus of the malaria programs in Madagascar.
7. Once the national scale up channels were identified, participants discussed on the selection of the district for the pilot program based on four criteria: (1) a district that has recently completed the mass distribution; (2) a district that has high burden of malaria; (3) NGO partners are present and active in commodity distribution; (4) district that has easy to access and hard to reach spots in order to pilot both situations. Out of the workshop, two districts were retained, a south eastern district, Vohipeno and a north eastern district Tamatave II.
After the workshop, the NetWorks team met with Alyssa Finlay (PMI team) to debrief about the outcome of the workshop and gather more information about the field mission. This meeting was also an opportunity to inform the NMCP about the NetCALC results, discuss logistics, and selection of partners and site for the pilot. During this meeting the NetWorks team inquired and obtained contact information from the different pertinent organizations and partners in the selected district.
Stakeholders and continuous distribution assessment:
The following week, the NetWorks team descended to the field to carry out the actual assessment of all possible CD channels as well as to identify stakeholders involved in distribution of any commodities in the district of Tamatave II. This ten day assessment enabled the team to conduct in-depth meetings with the following partners in Tamatave: PSI Madagascar, CRS Madagascar, ODDIT, RTI Madagascar, SALAMA, Medecin Inspecteur (District Medical Chief), mayor of rural communes, head of Fokontany, and Community Health Workers. Because of schedule conflict, communication with the District Director of Education (Chef CISCO) was made by phone. In addition to the in-depth examination of the distribution options, the team also assessed the different supply chain models and their effectiveness as well as collecting information on costs. Additional information was gathered upon return to Antananarivo from each of the partners’ central offices to cross-check the accuracy of the field data.
Debrief with USAID/PMI:
After the 10 days field trip and a debriefing meeting with NMCP, NetWorks team presented their initial findings to the USAID/PMI and Washington Malaria Operational Plan (MOP) team in Antananarivo. This debriefing meeting included a power point presentation demonstrating the different continuous distribution options available in the country and strategies that would work under current conditions: (1) A continuous distribution strategy for the pilot district that will be implemented under the current political restriction. (2) A continuous distribution strategy for a national scale up using government structures. Overall the USAID/PMI and MOP teams were very pleased with the presentation. After thanking the NetWorks team for their assessment work, Madagascar PMI ensured them that PMI will make additional nets available to complete the 42,500 nets needed for the pilot program.
Below is the summary of two continuous distribution strategies presented to USAID/PMI and MOP Washington teams:
First continuous distribution strategy:
The first CD strategy was a community based distribution channels using community structures to distribute LLINs to children completing immunizations, pregnant women, and eligible community members. To ensure that nets will reach households with pregnant women (on first ante-natal care visit) and children completing immunization, Community Health Volunteer (CHV) will identify the target group and give them coupons to be then redeemed at the Fokontany religious leaders (point of distribution) for new net (free of charge).
Community members eligible for a new net had to meet the following criteria, : (1) sleeping space of is not covered; (2) just married; (3) newcomers to the village; (4) LLIN is ripped and un-repairable (two holes the size of a human head); (5) LLIN was destroyed in a natural disaster such as a fire or a cyclone. For this strategy to work, CHV will identify and distribute voucher to households or individuals that qualify for a new net or voucher. A voucher can then be redeemed for a free net at the local religious leader’s house.
The below diagrams represent the flow of LLIN distribution and data reporting proposed for the pilot district of Tamatave II.
Figure 1: Commodity and reporting flow for community based LLIN distribution targeting pregnant women and children completing immunizations.
Figure 2: Commodity and reporting flow for community based LLIN distribution for eligible community members
Second continuous distribution strategy:
The second CD strategy was a continuous distribution system using government structures such as health facilities and schools. Distribution through community-based structures (including social marketing) will also complement this strategy.
· Distribution through health facility: For this, distribution of LLINs to pregnant women and children completing immunizations will be carried out at health facility level (public and private). ANC nurses or midwives will give a free LLIN to every pregnant woman coming for her first ante-natal care visit. For EPI, LLIN will be given to each child completing his or her immunizations.
Figure 3: Commodity and reporting flow for health facility based LLIN distribution for pregnant women and EPI
· Distribution through schools: For this strategy to work, nets would be delivered free of charge for school children in the first and fourth grades of primary school (CP1-CP4). Distribution at primary level would be done according to class registers and enrolment figures, led by the District Director of Education (Chef CISCO) and District Medical Chief (Medecin Inspecteur) in conjunction with the School Master (Directeurs d’Ecole) and head of the local health center (Chef CSB I or CSBII).
Figure 4: Commodity and reporting flow for school-based LLIN distribution for children in the 1st and 4th grades of primary schools
· Distribution through community based structures: This strategy will follow the same channel as described in the above pilot strategy. Nets will still be distributed for free to all qualified community members presenting vouchers at the religious leaders’ house.
· Distribution through social marketing: Distribution through social marketing will also complement the above described channels to ensure that those willing to buy nets can do so in the Fokontany. For this private sectors (retailers and NGOs) will play a crucial role to ensure that LLINs are available at a subsidized-cost at the Fokontany Level. Socially marketed LLINs will be managed by PSI from the central level to the distribution sites with the support of wholesalers and NGOs. For urban and peri-urban communities, distribution will be supported by the wholesalers system. Rural communities will be receiving their LLINs through the distribution point (PA) and NGOs circuits. For this, PSI distribution staff member travels with their vehicles will be visiting every PA and NGOs at commune level to deliver LLINs, monitor the net distribution/sale records, and cross-check the stock balances.
Figure 5: Commodity and reporting flow for social marketing LLIN distribution for the community members
For more information about the Madagascar draft implementation guideline for continuous distribution in the pilot district and for a national scale up, please see Annex II of this report.
ANNEX I:
The field and central level data fed into the NetCALC tool to simulate different scenarios of the potential distribution channels.
Below are NetCALC outputs and strategy scenarios proposed for the district of Tamatave II:
Figure 1:
Fig1: Fig. 1 Shows that as at 2011, the population of the district of Tamatave II was estimated at 235,250 with an average household size of 5.0 and an annual growth rate of 2.9%. 100% of population in this district is said to be at risk of malaria.
Figure 2:
In Fig. 2 data from the MIS 2011 reported coverage with any net at 80.40% and coverage with an LLIN at 74.00% for the district. After placing the DHS data collection for Tamatave II as 2008, the results of NetCALC calculation show that a total of 225,350 LLIN have been distributed within the district to date. Partners instructed that the net survival rate in Madagascar is 2 years. Shown to the graph on the right, the current national coverage of ITN ownership is 73.9% and access to LLIN is 67.1% (universal coverage). It also shows that after 2012, coverage will start to drop over time if no LLIN distributions are planned and conducted.
Figure 3:
Fig 3 presents the number of LLINs needed for the district distribution to reach the 90% agreed coverage target. Based on the numbers seen in Figure 3, the “Net gap if no replacement” line shows the number of nets that would need to be distributed at a specific point in time. For example, if Madagascar stopped net distributions in that district today and decided to start again in 2017, 139,223 will need to be distributed to reach the 90% agreed coverage target. “Annual net replacement need” shows that 22,287; 51,384 and 55,330 LLINs are needed to reach an 90% coverage rate in 2013, 2014 and 2015 respectively. Also, the “cumulative net replacement need” shows the cumulative number of nets needed each year starting in 2014 through to 2023.
Figure 4:
Fig. 4 represents the different channels of continous distribution that the NetWorks team thought is feasible to improve and sustain a national coverage of 90%. A combination of routine channels such as ANC and EPI were selected for LLIN distribution. Other channels such as community-based distributions were also considered. With current national contact rates for ANC and EPI, the team determined that ANC and EPI channels alone were not enough to improve LLIN coverage and maintain at a rate of 90%. Once community based distribution (to reach at least 60% of households with an average of 1 net per household) was added to the health ANC and EPI channels, coverage rates improved but did not reach the 90% target. Based on 2011 PSI Madagascar’s sales, social marking is currently covering around 4% (the equivalent of a total of 1,800 Ssuper Mmoustiquaires sold) of household with 1 net withing the district. This 4% coverage is already factored in the 60% of households to be covered above. If the social marketing of nets is sutained or increased (with communication initiaties in urban and peri-urban communities), coverage would improve.
With the current political restrictions, the pilot program will be implemented a channel designed to mimick the ANC and EPI program. The idea is that at community level, CHV will give a free voucher to every pregnant women right before or after her first ante-natal care visit. This can be done through regular house visits or during counseling at the CHV’s kiosks. CHV’s will also give vouchers to each child completing his or her imunizations. The other target group in this community based distribution channels are community members. They are eligible for a net when they meet the following criteria: (1) the household sleeping space is not covered; (2) just married and do not have net yet; (3) newcomers to the village; (4) has net but ripped and unrepairable (2two holes the size of human head); (5) LLIN was destroyed in a natural disaster such as a fire or a cyclone