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Who to include
ITN distributions include a wide range of stakeholders. Inputs from diverse players will enrich the description of the context and the consideration of possible approaches for ITN distribution.
The strategizing process will and should be led by the Ministry of Health (MOH) and the NMCP, as stewards of malaria control interventions in each country.
The NMCP will probably know and understand the stakeholders involved, who can influence the ITN distributions in the country. The NMCP should consider including representatives from all the groups below, as well as other locally relevant stakeholders:
[su_accordion][su_spoiler title=’Objective 1: Understanding the background’ class=’greendiv bluediv’] All main stakeholders involved in planning or decision-making should receive the information included in the Background section of this website. Hand-outs of some of the background information are provided (the first two tools listed). Depending on the context, the decision may be to provide copies of the material to relevant stakeholders for their own reading, or to present the material during the meeting. It may also be useful for stakeholders to review the experiences of other countries by using the Lessons in Brief located on the Country Examples tab.
Whilst the material is being reviewed, local experience with the different distribution mechanisms should be considered, thinking through the following general questions:
[su_spoiler title=’Objective 2: Describing the context, setting targets, defining needs’ class=’greendiv bluediv’] At this stage, the country context is described at a level of detail sufficient to support the development of a CD strategy appropriate to the setting. The appropriate choice of mechanisms will also depend on what ownership or access targets the country is aiming for and what quantity of ITNs is needed. All these points will be described, defined, and agreed to at this stage.
Describing the context
A range of information is needed to guide selection of a set of ITN distribution mechanisms that will be appropriate and provide sufficient ITNs to maintain target coverage.
Information and data that will be needed are described in a table with guidance on possible sources of information.The table is provided as a handout for download here.
The data required includes some that are needed to use NetCALC (an excel-based modeling tool that is designed to model scenarios of CD approaches based on country-specific data and provide estimations of the ability of varied channels to overall universal coverage), which will assist in the planning process; some information is not specifically needed for NetCALC, but rather is descriptive contextual information that will help inform discussions and thinking concerning the most appropriate distribution channels for the context.
The information needed to describe the context is in the following categories:
Information in these first two categories guides the calculation of the number of ITNs needed annually to reach and maintain targets and the number of ITNs that can be delivered through different mechanisms. For example, data on the proportion of the population that attends at least one ANC visit will help determine how many ITNs can be turned over through an ANC-based distribution mechanism.
This category includes all information and data to help guide the selection of efficient and cost-effective channels to reach the intended groups, such as details on service utilization (access) and program efficiency. In this category, consideration of geographical differences or differences between population groups (gender, socio-economic status, etc.) will be particularly important.
This category includes a wide range of information that will help inform discussions and highlight areas where action could be taken to improve the efficiency and effectiveness of continuous ITN distributions. An example is the cost of transportation and government per diem rates, which can have a considerable impact on the overall cost of the mechanism.
Considering specific sub-groups
An important part of describing the context will be to consider differences within the country. Many contextual factors may vary within a country or between population sub-groups. For example, important variations in such factors as current ITN access, household size, and access to possible distribution channels. Differences may be related to geographical area, urban/rural setting, gender, socio-economic status, or other characteristics specific to the country.
In planning, a balance is needed between the use of overly generalized national averages and overly detailed consideration for every possible variation.
Box 1 below displays the example of Uganda (prior to the 2013–2014 universal access campaign), showing a selection of population sub-groups that could be considered for planning purposes. This example represents a good balance between a high level of detail and a feasible amount of information to guide planning.
Wherever possible, collect the contextual information described in the Benefits and potential drawbacks of routine ITN distribution table on the Introduction to Continuous ITN Distribution for the different sub-groups considered important for planning.
As planning moves forward, the strategy mix developed will include mechanisms that ensure all groups can access ITNs.
[su_box title=”Box 1. Selecting sub-groups for special consideration during planning: the example of Uganda” style=”glass” box_color=”#000000″ title_color=”#FFFFFF” radius=”3″ ]
Higher than average ITN ownership, given the focus of donor money in this area Known to have higher than average coverage of trained and functioning community-based health networks (Village Health Teams)
Urban populations Higher than average numbers of nets per net-owning household Higher than average access to commercial outlets and routine channels
North Eastern, Karamoja region Lower than average ITN ownership Lower than average access to routine channels; almost no access to the commercial sector
Living >10km from a health facility Lower than average access to routine channels In the Ugandan setting these populations are also known to have lower than average access to commercial outlets.
[su_box title=”Box 2. Sub-group Rationale Defining the targets” style=”glass” box_color=”#000000″ title_color=”#FFFFFF” radius=”3″ ]
Part of the context is the targets for ITN coverage that the country aims to achieve and maintain.The targets of interest here are for ownership of ITNs only. Use of ITNs is, of course, the ultimate behavior essential to preventing malaria. The task here, however, is to design a ITN delivery strategy that meets the country’s ITN turnover needs and reaches all population groups. Therefore, the strategy must work towards ownership targets. Targets for ITN use will be addressed through concomitant communication and behavior change strategies that, whilst deserving of as much attention as the delivery strategies, are not the subject of this document.To allow planning, the national targets must be stated clearly as an indicator and a percentage or proportion.
For example: 85% of population has access to ITN within the household Determining the needsThe will help you to calculate annual ITN needs to reach and then maintain stated ITN ownership targets. You will need to enter into the tool your target and your current status against your target indicator.
[su_spoiler title=’Objective 3: Planning an appropriate CD strategy’ class=’greendiv bluediv’]
Note that this strategy will remain a draft until the field assessments (Step 2) have been conducted to determine the appropriateness and feasibility of the proposed channels.
During this section of the workshop, the guidance below will be used with the NetCALC tool. Different continuous distribution mechanisms, appropriate to the strengths and weaknesses of different settings, will be considered, taking into account a range of issues.
The best mix of distribution mechanisms depends on the priority objectives in the country. While meeting and maintaining ownership targets is key, most countries also have other important objectives, which may include one or more of those listed below:
The country’s priorities will be considered in the decision-making process, which is summarized below and described with more detailed step-by-step guidance in the VectorWorks document, Continuous Long-lasting Insecticidal Net Distribution: A Guide to Concepts and Planning, which you should use during the workshop.
This section will help you decide which mix of distribution mechanisms is most appropriate to your setting. You will move through four steps (a–d), completing a strategy matrix; the blank version is a handout. You may replicate this on paper, or in a PowerPoint slide, and complete it during the stakeholder discussion. Each of the four steps in the decision-making process requires some modification to the matrix.
Step a: List the important population sub-groups or areas that may need particular consideration.
Step b: Identify distribution channels and other mechanism criteria (channel, cost, targeting, etc.) that are appropriate for your context, considering the possible need for different mechanisms in different parts of the country, or to reach different sub-groups. See below for more guidance on achieving this. The decision table, which will guide the discussion, is available as a handout here. As you move through this, complete the strategy matrix.
Step c: Determine which distribution channels will best be combined to meet the total ITN needs to maintain target ownership levels, without allowing levels to drop too low and not oversupply ITNs. More guidance on achieving this is given below. Use NetCALC to work through this stage.
Step d: Review stage. Considering whether the chosen mix will allow reasonably equitable access across all geographical, economic, and other population sub-groups. Come back to the strategy matrix and then revise based on NetCALC outcomes. See below for more guidance on achieving this. The handout ‘main options for delivery channels’ may be helpful to have during the discussion. There is sometimes a tension between wanting to have as many channels as possible (in order to reach every person or to be able to demonstrate one’s ability to be able to keep up with the latest innovations) and affordability and feasibility (Box 1). It might be advisable to focus on implementing a few channels well first so those channels are reaching their full potential, then consider widening the eligibility criteria for those channels.[/su_spoiler] [/su_accordion]
Once a draft strategy is in place, it is time to move to the next step – conducting a field assessment.
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