GOVERNMENT OF UGANDA
Report on the Mass Distribution of
Long-Lasting Insecticide-Treated Nets
to Achieve Universal Coverage in Uganda
Ministry of Health
Plot 6 Lourdel Road, Wandegeya
P. O. Box 7272, Kampala, Uganda
October 2014
Draft 3
Table of Contents
List of Acronyms 3
Executive Summary 6
Introduction 7
Key Points 9
Planning and Coordination 15
Administrative Results 21
Operations, Monitoring and Evaluation 23
Logistics and Supply Chain Management 33
Social Mobilization and Behavioural Change Communication 42
Budget and Financial Management 45
Conclusion 47
References 49
Annex 1. Persons Interviewed 53
Annex 2. Implementation Guidelines 54
Annex 3. BCC activity Plan 54
Annex 4. Terms of reference for NCC and district teams 54
Annex 5. District coverage tracking sheet 54
Annex 6. Original Budget 54
Annex 7. Distribution schedule 54
Annex 8. Household registration tool 54
Annex 9. Logistics tracking tools 54
List of Acronyms
ACHS / Assistant Commissioner Health ServicesAMP / Alliance for Malaria Prevention
ANC / Antenatal Care
ASMSC / Advocacy and Social Mobilization Sub-Committee
BCC / Behavior Change Communication
CA / Cooperative Agreement
CCM / Country Coordinating Mechanism
CIA / Central Intelligence Agency
CID / Criminal Investigating Detective
CMA / Commodity management assessment
CWC / Child Welfare Clinics
DFID / Department for International Development
DGHS / Director General of Health Services
DHE / District Health Educator
DHIS2 / District Health Information System
DHO / District Health Officer
DHS / Demographic Health Survey
DHT / District Health Team
DISO / District Internal Security Officers
DTF / District Task Force
EPI / Expanded Program on Immunization
FCO / Focal Coordination Office
GF / Global Fund
GFATM / The Global Fund to Fight Aids Tuberculosis and Malaria
GISO / Gombolola Internal Security Officer
GOU / Government of Uganda
HDI / Human Development Index
HSD / Health Sub District
ICCM / integrated Community Case Management
IPTp / Intermittent Preventive Treatment for malaria during pregnancy
IQR / Interquartile range
ITN / Insecticide Treated Nets
JHU-CCP / Johns Hopkins University Center for Communication Programs
JSI/DELIVER / John Snow Inc./ Deliver Project
LC / Local Council
LLINS / Long-Lasting Insecticide treated Nets
M&E / Monitoring and Evaluation
MC / Malaria Consortium
MHSDMU / Medicines and Health Service Delivery Monitoring Unit
MOE / Ministry of Education and Sports
MOH / Ministry of Health
MoU / Memorandum of Understanding
NCC / National Coordination Committee
NDA / National Drug Authority
NMCP / National Malaria Control Programme
OSC / Operations Subcommittees
PMI / President’s Malaria Initiative
RBM / Roll Back Malaria
RC / Ministry of Health Resource Center
RDC / Resident District Commissioner
RH / Reproductive Health
SC / Sub County
SMP / Stop Malaria Project
TPL / Third Party Logistics
UBOS / Uganda Bureau of Statistics
UGX / Uganda Shillings
UNBS / Uganda National Bureau of Standards
UNDP / United Nations Development Program
UPDF / Uganda People’s Defense Forces
UPF / Uganda Police Force
USAID / United States Agency for International Development
USD / US Dollars
VHT / Village health teams
VPP / Voluntary Pooled Procurement
WHO / World Health Organization
Executive Summary
Malaria is the leading cause of morbidity and mortality in Uganda, accounting for approximately 30-50% of outpatient visits at health facilities, 15-20% of all hospital admissions, and nearly half of inpatient deaths among children under five years of age. From 2012 to 2014, Uganda conducted the largest net distribution program in the world to date. This historic campaign combined the efforts of multiple donors – USAID/PMI, Global Fund, DFID and World Vision – the technical expertise of the Ministry of Health and implementing partners and political leadership at all levels – to achieve unprecedented levels of net coverage in Uganda.
The campaign sought to reduce malaria-related morbidity and mortality by increasing the proportion of households with at least two LLINs to 80%. Unlike the 2010 campaign which targeted pregnant women and children, this universal coverage campaign aimed to reach the majority of the population, regardless of age or pregnancy. According to administrative data, over 22.2 million nets were distributed and coverage of around eighty-nine percent (89%) of the registered population of 41,034,354 Ugandans was achieved.
Strong and decisive leadership was required for a campaign of this magnitude to take flight. The involvement of top leadership and donors gave the campaign the resources and impetus to work with great coordination and dedication. Using rolling waves provided optimum use of time and human resources, allowing work activities to move forward across multiple parts of the country. The cross-sectoral involvement of government structures - such as the village health teams (VHTs), district and sub-county stores, administrative and health officials, the police and armed forces, and the Medicines and Health Service Delivery Monitoring Unit (MSHMDU) - helped save costs in storage and administration, reduced bottlenecks in implementation and provided a platform for ownership at political, administrative and community levels.
The universal coverage campaign has led to great strides in malaria control. The World Health Organization estimates that nearly 53,000 deaths among children under five could be averted as a result of the universal coverage campaign. However, history shows that without sustained effort, these gains will be lost. Families continuously need new nets through births and migration and as nets wear out in homes. A recent review of malaria resurgence events in Africa found that the vast majority could be attributed in some part to the relaxation of malaria control activities.
Uganda’s National Malaria Reduction Plan 2014-2020 calls for the country to sustain universal access to LLINs. It calls for Uganda to leverage existing systems – such as schools, antenatal care and immunization services, private providers and commercial outlets – to distribute nets on an ongoing basis to ensure that families can access nets when they need them.
As the country faces forward, it will be vital for it to accelerate the implementation of the National Malaria Reduction Plan and fulfill the vision of a malaria-free Uganda. As the universal coverage campaign has shown, it is clear Ugandan government structures and partners at all levels can be called upon to execute an initiative of this scale.
Introduction
The Republic of Uganda is a landlocked country in East and Central Africa with a per-capita income of US$ 1,168 per person. Agriculture is the most important sector of the economy, employing over 80% of the work force. Approximately 15% of the population lives in urban areas. The formal health care system consists of government and private facilities ranging from regional hospitals to health centers II, III, and IV, and where supported, community-based health workers called Village Health Teams. The country’s maternal mortality ratio stands at 438 deaths/100,000 live births, infant mortality rate at 54 deaths/1,000 live births and the under-5 mortality rate at 90 deaths/ 1000 live births (UBOS 2012).
Malaria is highly endemic in 95% of Uganda, with 90% of the approximately population at risk of infection. The remaining 5% consists of unstable and epidemic-prone transmission areas in the highlands of the south- and mid-west, along the eastern border with Kenya, and the Northeast border with Sudan. In some areas of northern Uganda, the entomological inoculation rates (infective biting rates by the mosquitoes that transmit malaria) are among the highest in the world (UBOS 2010).
The Central, Eastern, and Western regions of the country have two rainy seasons per year, with heavy rains from March to May and light rains between September and December. Due to these climatic conditions, Uganda’s topology ranges between tropical rain forest vegetation in the south and savannah woodlands and semi desert vegetation in the north. Malaria is more prevalent after the end of the rainy season. (UBOS 2012)
Figure 1. Map of Uganda Showing Malaria Endemicity
Talisuna et al, 2013
Uganda recently launched the National Development Plan ‘Vision 2040’ that articulates strategies to transform the country into a competitive upper middle income country with per capita income of US$ 9,500. The Ministry of Health (MoH) is expected to contribute to the 2040 vision through improving the health status and life expectancy of the people of Uganda and malaria reduction will play a key role in achieving these goals. (GOU 2013)
Considerable efforts to combat malaria have been put in place by the Ministry of Health. The proportion of households with at least one mosquito net has increased from 34% to 74% between 2006 and 2011. Six in ten households (60%) now own at least one insecticide-treated net compared to 21% in 2006; and 28% of households had at least one net for every two people in 2011. However, rates of intermittent preventive treatment in pregnancy remain low: only 37% of pregnant women have received SP during their recent pregnancy, while only 18% have received the minimum two doses (UBOS 2007; UBOS 2012). According to the Uganda Malaria Reduction Strategic Plan 2014-2020, malaria remains the leading cause of mortality among all age groups, accounting for 21% of all inpatient deaths in 2012/13. It is also a leading cause of out-of-pocket health expenditures, accounting for 3% of households’ annual income (MOH 2014).
Long-lasting insecticide-treated nets (LLINs) are a critical and highly effective component of malaria prevention and control programmes. Net use has been shown to reduce all-cause mortality in children under five years of age by about 20 per cent and malarial illnesses among children under five and pregnant women by up to 50 per cent. LLINs not only protect individuals sleeping under them from being bitten, but the insecticide also kills mosquitoes that land on nets, reducing overall malaria transmission in the community (AMP 2012).
Until relatively recently, efforts to scale up access to ITNs targeted those at greatest risk of malaria, namely children under five years of age and pregnant women. To further reduce malaria morbidity and mortality and to strengthen health systems, Uganda adopted the 2007 World Health Organization recommendation calling for universal coverage of the entire population at risk of malaria.
From 2012 to 2014, Uganda embarked on a nationwide universal coverage campaign. The goal of the campaign was to contribute to the reduction of morbidity and mortality due to malaria, through the specific objective of the campaign of achieving universal coverage, defined as increasing the proportion of the households with at least two LLINs to 80%.
This report outlines the steps taken to implement the campaign. It highlights challenges faced and actions taken. It records the facets that worked well, the areas that needed improvement and provides recommendations based on these experiences.
Key Points & Recommendations
Administrative Coverage
· Universal coverage was defined as one net for every two people. The campaign’s goal was to to reduce malaria-related morbidity and mortality by increasing the proportion of households with at least two LLINs to 80%.
· The country distributed 22,267,777 LLINs to a registered population of 41,034,354 people, ensuring 89% of the registered population has access to a net.
· Almost all of Uganda’s districts (92.1%) achieved above 85% coverage; the lowest coverage was recorded in Serere district (62%), which was a pilot district and followed a one net per household allocation mechanism.
· Registration found 15% and 25% percent higher population in rural and urban areas, respectively, compared to census projections. Amongst the registered population, 23% (9,645,628) were children under five and 3% (1,167,744) were pregnant women.
Planning and Coordination
· When trying to implement such a major campaign, it is nearly impossible to align all the resources involved. Such a massive endeavor really does require a great deal of up-front planning, pre-visits, and close monitoring to respond to emergent changes to ensure the smoothest implementation possible.
· The strong and committed leadership of the Director General of Health Services was key to the success of the campaign. The National Coordination Committee (NCC), through the Director General of Health Services, developed the implementation guidelines and provided leadership and direction while working with the District Task Forces which were headed by Resident District Commissioners.
· The implementation guidelines did not give authority to districts to lead the campaign at the district level, creating operational inefficiencies. Additionally, little consideration was provided for areas with unique implementation needs such as sparsely populated, mountainous, and/or hard to reach areas. There was also little room for locally-adapted interpersonal communication (IPC). Future campaigns should strongly consider a hybrid style of management that clearly stipulates roles that will be delegated to districts.
Operations, Monitoring and Evaluation
· Campaign operations were managed by the District Task Force (DTF) team with support from district coordinators and supervisors.
· Cascade training was conducted from the national to the sub-county levels. There was little variation in the training, and net hanging messages were generally received correctly. However, Local Council ones (LC Is) interviewed did not know the reason for distributing nets using the 1:2 ratio, or how long the LLIN would last.
· Number of people trained: 191,662. This number included: 1,709 district task force team members, 8,450 sub-county task force team members, and 181,503 village health team/community resource persons.
· Village Health Teams were used to register households. In rural areas, VHTs reported needing more than the two allocated days to complete their requirement of registering 100 households. Individual household data was collected using a census methodology, and was managed by the MOH Resource Centre (RC). A team of 150 personnel were hired to manage the data center and a fully computerized data capture and input system with multiple stages of validation was instituted to ensure no data was lost.
· For most districts, allocation was based on 1 net per 2 people in the household. For the urban distribution in Kampala and Wakiso, a shortage of nets required allocation of 1 net for every home and an additional net if the home had a pregnant woman or a child under 5.
· Two distribution methodologies were used in the campaign. Fixed-point distribution was used in peri-urban and rural areas, while door-to-door distribution was used in urban areas. In urban areas, heads of households were identified by using registered telephone numbers as unique identifiers.