By Albert Kilian, Technical Director, Tropical Health LLP
In a recently published article, Zöllner and colleagues provide a very interesting assessment of ownership and equity of insecticide treated nets (ITN) following a mass distribution campaign in Burkina Faso. They report results from two representative household surveys in the Nouna Health District, using a three-stage cluster sampling design – one survey was undertaken before and the other about three months after the campaign. The objective was to assess the extent to which universal ownership coverage, defined by WHO as “at least one ITN for every two people” in the household, was achieved and whether there were any inequalities in the distributions, with respect to level of poverty.
The organisation of the ITN distribution, as described by the authors, appears to have followed current best practices: first, a house-to-house registration exercise was carried out, during which the number of nets needed for each household to reach the “one ITN for every two people” was determined, based on household members. Unfortunately, the authors do not tell us whether or how existing nets were taken into account. This is usually a critical aspect of campaigns where some ITN are already available in the families, as was the case here, because it raises the question of whether or not to ignore them or include some or all of them in the count (e.g. depending on their age or condition); the second step is for the registration teams to then issue coupons for the number of ITN allocated to the household, which can be redeemed at a defined day and distribution point, which in this case were the health facilities in the district.
There is no perfect campaign
The success of the campaign was very clear and unequivocal: it increased the minimal spatial coverage of “households with at least one ITN” from 59% to 99% and the households with “enough ITN for all family members”, i.e. those with at least one ITN for every two people, from 3% to 52%, with an additional 34% of households having almost enough ITN for all with a ratio of one ITN per three people; and it did this with a high level of equity or in the case of universal coverage with “enough” ITN even in a pro-poor fashion (concentration index -0.031, 95% CI -0.062, 0.004).
Although the authors point out that to date there is not much data published on similar campaigns, this has to be considered a very successful campaign based on unpublished experiences from various countries in Sub-Saharan Africa and a huge step in achieving significant reductions in malaria transmission. Nonetheless, Zöllner and colleagues highlight that households further away from health facilities and larger families were not reached with enough ITN and at the same time point out that only 83% of the ITN provided for the campaign were actually distributed. This leads them to conclude as one of the article key messages that,
“programme managers should design … campaigns so that they reach the entire population and should calculate for sufficient mosquito nets…”
I am certain that the authors made this recommendation with good intentions but am equally certain that programme managers do not intentionally plan NOT to reach the entire population. But the experiences from almost ten years of organising mass ITN campaigns has clearly shown us that even under the best of circumstances and with the best of resources, a 100% reach is simply impossible. And the devil lies in the details of micro-planning rather than the overall calculation of what would be “enough” ITN for a given population. The reasons for imperfections are many: i) census data rarely match the reality on the ground; ii) registration teams do not always make it to the most remote households and hence fail to register people or run out of coupons to hand out; iii) a certain part of the population is not around their usual homes at the time of the registration and are missed; iv) people forget the day of the distribution, loose their coupons or fall sick so that they cannot attend; and v) ITN at the distribution point may run out at times even with sophisticated schemes of pre-positioning and daily update of stock via mobile phones.
From need to demand
But to me the important question to ask ourselves in the public health community is not, how we improve the mechanics of a successful campaign but rather, how do we sustain the levels of ITN coverage needed (in conjunction with other interventions) for highly malaria endemic countries to significantly reduce transmission and move towards sustained malaria control and closer to “pre-elimination”. With increasing data available from efforts to monitor the “survival” of ITN distributed through campaigns it is quite evident that losses of nets begin a few months after distribution, making it obvious that even a “perfect” campaign would not resolve the need for mechanisms to continuously replenish existing and emerging gaps in household ITN ownership. This is what we would then call a comprehensive strategy for continuous ITN distributions. There is general agreement that some form of continuous distribution is needed but how exactly we approach this is still under debate. Here I believe that the old discussion around ITN is resurfacing where we had all previously agreed that campaigns are the best way to rapidly scale-up ITN coverage. On the one hand there are those who see ITN primarily as a public health intervention, such as a vaccine, and want to implement coverage as central planners of public health with experts in governments and donor agencies deciding who needs a new ITN when and where. On the other hand there are those of us who believe that ITN are first of all a consumer product that needs to be accepted by the users and become part of daily life for those who are to benefit from it. And this “net culture” which we see as a critical element to turn ITN ownership into regular use will develop far better if we allow, and even encourage, households and families to take responsibility for obtaining additional and replacement ITN. Certainly, the public sector needs to ensure that households have access to suitable products and that also the poorest or most remote parts of the populations at risk will be able to obtain new ITN, requiring a country and situation specific mix of approaches. Need for ITNs will only be turned into demand if we build on the initial step among families and universal coverage will be maintained through a sustainable continuous distribution system for ITN that tries to avoid repeat campaigns wherever possible and allows all sectors of society, all parts of the health system – including the private sector – to play an active part.
