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Malawi, Ntcheu District: net use assessment 33-months post-distribution

The 33-months post-distribution net use check-up (PDCU) is currently being conducted in Ntcheu District, Malawi.  Five percent of households, randomly selected, across 37 health centre catchment areas in the district were visited, unannounced, to assess net use and condition.
The data are being entered in Malawi now and may be viewed as they are entered. As soon as all data have been entered we will publish a summary of the results.
The specific nature of the data - at the health centre level - means the District Health Officer (DHO), health centre leaders, community leaders and other health workers are able to decide what targeted malaria control intervention might be appropriate in specific areas. In circumstances where health systems and resources are stretched, information that assists with targeted interventions can help with effective use of resources and that is the aim of this information.
We will provide our assessment of the data once all have been entered.
Background: Almost 268,500 LLINs were distributed in Ntcheu District from December 2011 to February 2012.

Professor Hilary Ranson joins AMF’s Malaria Advisory Group

Professor Hilary RansonAMF is delighted to announce Professor Hilary Ranson of the Liverpool School of Tropical Medicine (LSTM) has joined AMF’s Malaria Advisory Group (MAG).
The MAG advises AMF on many aspects of its activities including assessing target distribution locations and ensuring best practice in carrying out pre-distribution activities (including assessing household level net need and delivering malaria education), distribution management and verification, and post-distribution follow up.
Professor Ranson is one of the world’s leading authorities on insecticide resistance (IR). Hilary joined LSTM in 2001 and has been the Head of the Department of Vector Biology since 2010. She leads a portfolio of IR related research and advises widely on IR policy, including that relating to net distributions. She will be a very valuable addition to the group advising AMF.

Operational planning (12 months) and planning horizon (18 to 24 months)

The operational plan for a distribution typically covers 12 months. The planning horizon for a specific distribution is, however, typically 18 to 24 months as discussions to assess and approve a distribution start six months earlier and the funds required (we need to have funds in hand in order to have serious discussions) are aggregated in the preceeding months.
For the distribution in Balaka (Sep/Oct 2015), recently announced, the sequence of operational steps (simplified) are:

Nov 14: Distribution (new timing) confirmed
Dec 14: Budgets agreed
Jan 15: Planning starts
Feb 15: Pre-distribution registration survey (PDRS, all households) planning document received
Apr 15: PDRS carried out, including verification activities and report received
Apr 15: Nets ordered
Jun 15: Nets produced
Jun 15: Nets shipped (two month transit time)
Aug 15: Nets arrive in country, pre-positioned
Sep 15: Distribution of nets (Sep and Oct 2015)

Next Balaka, Malawi distribution brought forward to Sep/Oct 2015

The Malawi National Malaria Control Programme (NMCP) will be coordinating a country-wide mass distribution of nets during 2015 in 24 (of the 28) districts in Malawi. This follows the nationwide mass distribution on nets in 2012 and is therefore a re-coverage campaign. This timing is consistent with the three year repeat cycle common to many national programmes matching the degradation profile and useful life of the nets.
As a result of discussions between the NMCP and the wider Task Force group, within which AMF and our distribution partner Concern Universal are represented, and which coordinates and manages malaria control activities in-country, it has been decided a re-coverage distribution in Balaka during 2015 is both the optimal action for protecting the people of Balaka and means the Balaka three year distribution cycle will be aligned with the rest of Malawi.
This means the distribution is now planned for September and October 2015 rather than September and October 2016.
As a result, all specific donations to AMF that are funding this distribution which had been previously designated as ‘underwriting donations’ (given it was considered likely an early distribution, elsewhere, and prior to Sep/Oct 2016 would mean the specific donations would be moved to fund an earlier distribution) have now been designated as ‘confirmed allocated’ and will fund the Balaka distribution.
Further information:
A partial coverage distribution took place in Balaka in June 2012 conducted by the NMCP. The 70,000 LLINs found in place via an AMF/CU-conducted district-wide audit of all households were supplemented by the distribution of 154,230 LLINs in October 2013 which achieved district wide sleeping spaces coverage. By September 2015 at least 70,000 LLINs will need replacing (to protect some 130,000 people) as well as an estimated 30-40% of the nets distributed in October 2013 (an additional 45,000 to 60,000 LLINs to protect some 80,000 to 110,000 people). In addition, nets that have less than 12 months life remaining will be replaced which is anticipated will increase the number of nets required by a further 50,000, and population growth will add an additional 10,000 LLINs for a total requirement of up to 190,000 LLINs.

Dr Toby Ord, Giving What We Can: Effective giving

Dr Toby Ord, Founder of Giving What We Can: TEDx talk about giving effectively.

Donor reviews of AMF on Great Nonprofits

A number of donors to AMF have recently added reviews to the Great Nonprofits website and we are exceptionally grateful for the comments people have made. 

730,000 LLIN distribution agreed for North Ubangi district, Democratic Republic of Congo (DRC)

AMF has agreed to fund 730,000 LLINs for distribution in North Ubangi district in Equatéur province to achieve coverage of all sleeping spaces (universal coverage) across all eleven of the district’s health zones. The nets will protect approximately 1.3 million people and will be distributed in the first half of 2015 with specific dates being determined now.
The distribution is a partnership between AMF, who will be funding the nets and shipping cost to DRC, the UK's Department of International Development (DFID) who will be funding all non-net costs through the ASSP (Access to Primary Health Care) project and IMA World Health who will be responsible for carrying out the pre-distribution, distribution and post-distribution follow-up activities.
This is the second such co-funding and distribution partnership between the three organisations, following that in Kasai Occidental province to distribute 676,000 nets during August to November 2014.
DRC is one of the two most affected malaria countries in the world. It is estimated some 500 people per day die in DRC from malaria. Large scale net distributions therefore have the potential to make a significant improvement to the health of the communities protected.
At the same time, operating in DRC is challenging given the recent conflict, poor infrastructure, minimal access to health care, difficult geography and long distances between towns and villages.
The distribution of nets and follow-up will be strongly data-driven. The distribution will be accompanied by detailed monitoring and reporting. Post-distribution check-ups of net use and condition will take place on a six to nine month rolling schedule for three years. The detailed planning of the distribution and follow-up will respect the practicalities of working in such a challenging environment as that presented by DRC.  
DFID has significant experience in operating in DRC, including funding large scale net distributions, and has in-country presence. IMA World Health has worked in DRC since 2000 and currently manages a series of significant health initiatives across five of the country’s eleven provinces. They have significant management experience of conducting large scale net distributions.

Introduction of smartphone technology to collect distribution data

Our distribution of 676,000 nets in Kasai Occidental in partnership with IMA World Health (IMA) is our first one using smartphone technology for data collection. We see this as an exciting development with significant potential benefits including:
  • Acts against potential theft
  • Improved accountability
  • Greater transparency
  • Greater data accuracy
  • Improved cost effectiveness
  • Additional data can be collected
  • Reduced operational risk
The use of this technology may become a significant determinant of future net distributions that we fund. We will report publicly on our experience with the Kasai Occidental distribution and the data gathered.
IMA is using smartphones and open source software (which is free) to manage the data collection associated with the distribution of 676,000 LLINs in Kasai Occidental in DRC.
Gathering household level data, primarily the number of sleeping spaces in each household, but potentially the number of people and perfectly usable LLINs, as well as other profile data, is necessary if the aim is coverage of all sleeping spaces in a distribution zone.  
Paper based data collection is a common approach. However, if the data is not subsequently put in electronic form, it is difficult to check independently and monitor. There can be data loss risks if copies are not made and copying many thousands of pieces of paper can be challenging and costly. If data is put in electronic form, data-checking and sharing for independent monitoring can then happen. This latter approach has been our way of operating.
The use of smartphone technology, with data uploaded daily via wifi at health centres, removes many steps in the data management process and facilitates sharing of information. Early indications are of significant cost savings versus paper based gathering.
GPS data for net distribution. Courtesy: IMA World Health
GPS information can also be gathered helping to locate households and tie the number of nets delivered to each.
Use of this technology has the following potential benefits:
  • Acts against potential theft
    - Detailed household data underpins a distribution making theft at all levels difficult/potentially immaterial
  • Improved accountability
      - Data captured at registration and distribution is easily accessible and underpins post-distribution monitoring
  • Greater transparency
    - Easy to capture data which can be shared widely, including publicly
    - GPS data offers engaging/effective way of sharing information with donors using maps
  • Greater data accuracy
    - Simple data entry via tap screen, with quantitative and menu-driven answers
    - Error checking as data entered (for example, if more nets hung than sleeping spaces recorded, error shown)
  • Improved cost effectiveness
    - Fewer data management steps
    - Assuming familiarity with smartphones, minimum training is needed to use the data collection app
    - Open source software, so free. NB: Other commercial systems may be expensive and our sense is this has inhibited uptake.
  • Additional data can be collected
    - GPS data recorded for each household with ~6 metre average accuracy
    - Photos of household/householder/nets
  • Reduced operational risk
    - Lowers/removes risk of costly problems through data loss when only one paper copy of data exists 
Our understanding is that few are using this technology at present. The reasons may be two-fold. First, until recently most technology-led data collection solutions were supplied by commercial companies and were costly, inhibiting uptake. Second, some believe the collection of household level data in not necessary, and is either prohibitively expensive or operationally difficult. We would disagree on both counts. We do expect there may be teething problems with the use of the technology and we will report openly on what we find.

Behind the scenes: Specific emails so donors can track the nets they fund

We link individuals donations to specific distributions so donors can see where the nets they fund are distributed, and to keep donors apprised of progress we send each donor a small number of emails relevant to their donation over the course of a distribution.
A highly automated system helps us handle this targeted communication as efficiently as we can as there are often many donations being allocated to many different distributions with, on occasions, ‘underwriting allocations’ becoming ‘confirmed allocations’.
Currently, some 7,500 specific emails are being sent to a similar number of donors to let them know about the allocation of their donation to a distribution or update on progress with their distribution. The image above shows the progress of the emails at the time of writing. 

Why our distribution budgets are cost-driver based and why we publish them

Our distribution budgets are cost-driver based as this helps achieve accurate budgets and aids cost management. We publish them as we wish to share with donors how we spend funds entrusted to us.
Cost-driver based budgets are by their nature highly detailed. Each cost line is developed from elements that determine it. For example a ‘fuel cost’ budget line item would be calculated from the number of vehicles multiplied both by the expected litres of fuel per day and the cost of fuel per litre. Similarly an overall ‘transport cost’ would be developed from a similar approach to the expected cost of truck drivers and of vehicles, with all three items added to determine the overall transport cost.
The benefits of this form of detailed costing to the overall management of our net distributions are: 
  1. Helps with cost control and also ensures the work that needs to be done is fully costed
  2. Assists clear communication with our distribution partners and the use of templates minimises as far as possible the time the distribution partner spends on necessary administration easing as far as we can their workload
  3. Aids transparency with donors and others as to how we are spending funds entrusted to us
  4. Improves future budgeting through a close understanding of actual costs and how they break down 
In environments where there is the potential for cost management to be challenging, and this is true of the areas in which net distributions are conducted, attention to detailed budgets and following up on actual costs, and publishing them, is very important.
It is a strong indication to us when we build a relationship with a distribution partner, to whom we entrust many millions of dollars of nets, there is a willingness to work with cost-driver based budgets and to report on actual costs.
We see achieving efficient use of funds as an obligation and, given the substantial sums involved, this approach helps us to do our best to meet that obligation.

New layout of non-net cost information, including budget vs actual cost comparison

We have updated the layout of our non-net costs section and added significant budget and actual cost information.
We publish two levels of non-net cost information:
1. Summary level budget and actual cost information per distribution, which can also be viewed by project element for each distribution on the webpage. Project elements are: shipping, pre-distribution, distribution and each post-distribution check-up intervention.
2. Detailed cost-driver led budgets, showing actual and budget cost comparisons in excel documents.
We publish this information as we wish to share with donors how we spend funds entrusted to us. 

Mid-distribution weekly reports for Dedza distribution, Malawi

Weekly reports during a distribution keep us informed of progress and any issues.

Dedza distribution of 245,000 nets, Weeks 1 to 4
Good progress, 139,549 nets distributed so far. The distribution is going well with no major issues.
We encourage our partners to not hold back on reporting negative occurrences as we understand things can go wrong and plans have to adapt. We are obviously interested in the scale of any issues but are often more interested in how issues are resolved.
Concern Universal Malawi has been impressive in being entirely transparent with their reports and it is one factor that has led us to work with them repeatedly.

The challenges faced so far have been:
1. An isolated incident of 300 nets missing from one storage location. This is being investigated and pursued with the police as any nets missing is taken very seriously. 300 nets represents 0.12% of the total nets being distributed.
2. An inability to distribute nets in a number of villages, and the need to reschedule a net distribution, due to: 

  • misplacing villages in the wrong distribution clusters leading to an incorrect number of nets at a distribution point (being addressed through improved checking)
  • a lack of communication by local health workers to village leaders (this is being addressed)
  • some villages busy with elections, weddings or initiation ceremonies that were foreseeable (being factored into the timing of the distributions in the remaining villages)
  • deliberate duplicate registration of some beneficiaries (the nature of our verficiation procedures catches this sort of activity and the registration data was corrected)
  • issues with the identification of some beneficiaries due to illiteracy (resolution achieved with assistance from the village leader)
The above issues are considered by CU and AMF to be avoidable and lessons will be learned from them.
The following issues are considered to be largely unavoidable and are elements that have to be dealt with as they arise:

  • a truck breakdown
  • funerals taking place involving a significant portion of the village (sometimes a distribution can be moved to a nearby village; often a rescheduling is required)
Finally, a comment in the Week 1 report:
"Many villagers demonstrated their appreciation regarding the manner in which the net distributions were conducted, which they described as the most transparent ever done. This was achieved due to the involvement and participation of the local leaders and provision of a copy of the distribution register to the respective village head."

Balaka, Malawi, 6-month post-distribution check up report added

The key results from the post-distribution check-up (PDCU) of net use and condition are:

- 87% of nets hung, 70% in ‘very good’ condition. 25% in ‘OK’ condition
- 4,530 households (5% of those that initially received nets) and 7,977 nets were surveyed
These are strong results.
We publish the full PDCU results and the PDCU Report as well as the PDCU Planning Document on the Balaka distribution page.

396,900 nets on the way to Dowa District, Malawi

396,900 nets have shipped and will arrive in Dowa district in the middle of November for distribution from Dec14/Jan15 to protect 720,000 people and achieve universal coverage.

Our distribution partner Concern Universal will carry out the distribution.

AMF is funding both net and non-net costs, as was the case with the Balaka (2013) and Dedza (2014) distributions. We describe publicly the circumstances in which we cover non-net costs for a distribution.

A cost-driver led budget has led to detailed costings and we publish full budget details. Actual costs will be published at the end of the distribution.

The non-net cost per net is US$0.97. This covers shipping, pre-distribution activities (a district-wide household level registration to establish sleeping space net need), distribution and post-distribution follow-up (six, six-monthly check-ups of 5% of households, randomly selected and visited unannounced, carried out for three years post-distribution). 

Ntcheu, Malawi 33-month post-distribution check-up will start on 13 Oct 14

Monitoring net use and condition is an important element in optimising the protection of a population at risk from malaria.
This will be the fourth post-distribution check-up (PDCU) of net use and net condition in Ntcheu, Malawi following the June 2012 net distribution that achieved district-wide universal coverage of the population of some 550,000 people.
To date the results have been strong and we are keen to see the usage level and condition of the nets 33 months after they were distributed.
9,500 households, representing approximately 7% of those that received nets 33 months ago, will be randomly selected and visited unannounced.
The results will assist the District Health Officer (DHO) and National Malaria Control Programme’s (NMCP) decision as to when a re-coverage campaign should be conducted in Ntcheu so the people of Ntcheu remain protected.

Distribution of 676,000 nets underway in Kasaï Occidental Province, DRC

This distribution will achieve universal coverage in seven Health Zones in the Kasaï Occidental Province of Congo (Dem. Rep.), across a population of some 1.2 million people.

The distribution is being carried out by IMA World Health, with the UK Government’s Department of International Development (DFID) as a co-funding partner.

This will the first stage of a two stage net distribution approach that has the specific objective of maintaining sleeping space coverage at or above 80% for a period of four years.

The second stage will involve continuous monitoring of net use and condition, and also net gaps, with additional net distribution as appropriate via 'routine distribution' mechanisms.

In addition, 6,000 nets will cover all hospital and maternity beds across all health facilities in the seven Health Zones.


Distribution of 245,000 nets underway in Dedza district, Malawi

245,000 nets are now being distributed in Dedza district, Malawi. All nets will be distributed by the end of October.
These nets will protect some 440,000 people, helping to achieve universal coverage of all sleeping spaces in the district.
Pre-distribution work led by our distribution partner, Concern Universal Malawi, and carried out with the local government health teams, has involved visiting all 162,723 households in the district to establish net need per household. This allows an efficient, targeted distribution with each household receiving the number of nets each needs.
This pre-distribution activity allows significant engagement of community and health leaders in the net distribution process and associated malaria education elements. Community involvement is instrumental in ensuring an organised distribution and helping to achieve high levels of immediate net hang-up and sustained use.
Detailed distribution records, including household level data, will allow us to verify nets were distributed as intended. Independent supervision at the ‘moment of distribution’ ensures no nets are misappropriated.
The data collected during the pre-distribution phase will be used in the six-monthly post-distribution net use and condition check-ups, when 5% of households are selected at random and visited unannounced to gather net use and condition data. These (anonymised) data are made public, allowing us to report on the levels of net use achieved over time. The District Health Officer (DHO) and his/her team are able to use this health-centre level information to influence additional local malaria control interventions as they deem necessary.

Behind the scenes

We have added Behind the Scenes to the Transparency section of the site.
We show this information to be transparent but also for those who might be interested in some of the things that go on behind the scenes in managing the charity.

Many of AMF's systems are automated. This means many activities are handled very efficiently requiring only a few minutes of oversight each month. Importantly, it also means we are able to do things we would otherwise not be able to do because they now require minimal resources. 
Topics we have covered, many of which include live data, are:

  1. Allocating donations to distributions
  2. Reporting on Post-Distribution Check-Ups (PCDUs)
  3. Managing Gift Aid
  4. Converting and locking all donations in US$
  5. Sending personal thank yous to donors
  6. Monitoring new donations 

An update on distributions being assessed

We have just updated our future distributions page showing the progress made in approving seven distributions. 
In the coming several months we will be parallel assessing a number of distributions of 1 to 2 million nets in size and possibly one of 3 to 4 million nets in size.
You can view the current status of each distribution with visual and summary updates.

Distributions update, June 2014

We have made a US$6m commitment to four distributions in Malawi over four years and on Idjwi Island, DRC. The same level of accountability, achieved through distribution verification and post-distribution follow-up, applies to these as to previous distributions.

A provisional, large distribution in a province of the DRC will not proceed as the distribution agent was unable to agree to the process requested by AMF in the timeframe needed by our co-funding partner.

Of the $14.8m in-hand, we have now confirmed spending of $8m leaving $6.8m for further distributions.

Approved distributions

1. Malawi

This set of distributions extends AMF’s planning horizon, increases the number of districts within which AMF will take responsibility for mass distributions and allows us to continue monitoring net use and malaria data in the coming years.
We have made a US$5.6m commitment to four distributions over four years in Malawi totalling 1.4 million nets to protect 2.5 million people.
  • Dowa District, November 2014, 400,000 LLINs
  • Ntcheu District, October 2015, 350,000 LLINs
  • Balaka District, October 2016, 235,000 LLINs
  • Dedza District, October 2017, 430,000 LLINs
The addition of Dowa district brings to four the number of districts (of 28 in Malawi) where AMF is responsible for funding.
Our distribution partner Concern Universal has demonstrated the commitment and capability to carry out successful mass distributions achieving high rates of net coverage in our previous work in Malawi. We will continue to use the same distribution methodology.
The timing of these distributions reflects the expected life of nets in these districts following the initial 2012 (Ntcheu), 2013 (Balaka) and 2014 (Dedza) work. Returning to these areas allows efficient monitoring of net use and collection of malaria data. Our processes are continually revised to ensure the most effective results.
The precise number of nets will be calculated on completion of the household level pre-distribution surveys.

2. Democratic Republic of Congo (DRC)

120,000 nets will achieve universal coverage on the island of Idjwi in eastern DRC
AMF has approved a 120,000 net universal coverage distribution on Idjwi Island working with Amani Global Works (AGW). A 60,000 net distribution will take place during November 2014 in North Idjwi. We have been impressed with AGW's experience in North Idjwi and their commitment to accountability and transparency. Both parties will review the North Idjwi distribution once completed and intend to carry, out shortly thereafter, a similar universal coverage distribution in South Idjwi.
Provisional distribution not proceeding
We are not proceeding with provisional plans for a third and larger distribution in DRC. Within the timeframe needed by our co-funding partner, the distribution agent was unable to agree to the process requested by AMF. While we remain ready to adapt our practices to different environments, we are seeking to improve on standard net distributions. This is because we have found significantly higher levels of hang-up when these improvements have been implemented. 
We fully understand that not all distribution partners will share our priorities or wish to make changes to their normal routine. After extensive discussions we did not reach agreement on the detailed aspects of verification of the distribution or monitoring and evaluation within the timeframe necessary to secure a firm commitment from our co-funding partner. During the negotiation, significant budget cuts were also placed on our co-funding partner.
This was intended to be our largest DRC distribution after the successful conclusion of negotiations for the distribution of 676,000 LLINs earlier this year with a different distribution partner, IMA World Health. These took one month and  included swift agreement on distribution verification, monitoring and evaluation. AMF and IMA believe that the detailed follow-up checks which have become a feature of AMF work significantly improves net hang-up rates.
We recognise this can and should be adapted to take into account the country and regional requirements, so detailed discussions will sometimes be necessary to find an agreed outcome. However, we are reviewing this experience to learn from it and in particular assess how to reduce the risk of important differences arise late in the process. A Letter of Partnership Principles was agreed by the three parties at the start of discussions, which included a clear commitment to the inclusion of monitoring and evaluation activities. This did not prevent differences being raised on these issues late in the process.
We are also considering whether future distributions should focus on three to four distributions of one to two million nets each rather than a large distribution that would require all of AMF’s available funds. This would allow AMF more flexibility to exit discussions earlier if differences arise.

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