REPORT ON THE LONG LASTING INSECTICIDE TREATED MOSQUITO NETS CAMPAIGN NOVEMBER P a g e

Transcription

1 REPORT ON THE LONG LASTING INSECTICIDE TREATED MOSQUITO NETS CAMPAIGN NOVEMBER P a g e

2 His Excellency, The President holds a mosquito net during the closing ceremony of the LLIN campaign at Mulago grounds. He is flanked by the Rt.Hon Prime Minister Dr. Ruhakana Rugunda and the US Ambassador to Uganda, Scott Delisi 2 P a g e

3 ACRONYMS ANC ACTs BCC CAO CHC DFID DHO DISO DPC DTF GF HMU K&N JHU LC LFA LLIN PMI MOH NCC NGO PWC RDC UPDF USAID VHT WHO Ante natal care Artemensin Combination Therapy Behavioural Change Communication Chief Administrative Officer Communication for Healthy Communities Department for International Development District health officer District Internal Security Officer District Police Commander District Task Force Global Fund Health Monitoring Unit Kuhen and Nagel John Hopkins University Local Council Local Fund Agent Long Lasting Insecticide Treated Net President s Malaria Innitiative Ministry of Health National Coordinating Committee Non Government Organization Price Waterhouse Coopers Resident District Commissioner Uganda Peoples Defence Force United States Agency International Development Village Health Team World Health Organization 3 P a g e

4 BACK GROUND Malaria is the number one cause of mortality and morbidity in Uganda and kills an estimated 80,000 people per year. The most at risk populations are the pregnant mothers, children under five and the elderly. According to the National Malaria Control Plan of Uganda, the core interventions for the management of Malaria include use of long lasting insecticide treated nets (LLIN), in- door residual spraying (IRS) with focus on low and epidemic prone areas; and effective Universal access to Artemesin combination therapy (ACT) treatments. Others like prevention of malaria during pregnancy using intermittent presumptive treatment (IPT), advocacy and social mobilization, human resource development and strengthening monitoring and evaluation. The government has in the past tried to distribute LLINs to targeted or most at risk populations like pregnant mothers during ANC and under-5 children at OPD. During phase 1 of Round seven, 7 million nets were distributed across the country while in 2012, nets were distributed in the districts of Mayuge, Serere, Bugiri and Kaliro. As a means to mitigate the incidence of malaria morbidity and mortality, the government of Uganda with support of development partners embarked on a process of universal distribution of LLIN in Uganda. Although there had been isolated cases of distribution of LLINs to certain population clusters like most at risk populations, this particular programme was supposed to cover the entire population. The planning and design of the programme began in 2009 and it was only realized in 2013 when the Universal LLIN Campaign was officially launched in Uganda by H.E, The President of the Republic of Uganda on the 8 th of May The aim of the programme was to distribute LLINs to every house hold in Uganda in order to reduce malaria morbidity and mortality amongst the population. The strategy was universal coverage for the country which is defined in Uganda as one long lasting insecticide-treated net (LLIN) for every two persons in a household. However, the criteria changed in the central region districts of Kampala and Wakiso where one net was distributed per household. 4 P a g e

5 Guidelines for the various committees and the necessary tools for field teams were developed for the implementation of the universal LLIN campaign. Trainings were also conducted at various levels. MHU participated in both the development of guidelines and the trainings. The country was mapped into 8 waves with about 16 districts each except for the first and last waves. The activities were done per wave and included training, registration, transportation, storage, distribution and media campaign. The programme cycle was expected to end on the first of July 2014 but it extended to August The oversight of the programme was done by the National Coordination Committee (NCC) which included all Major stake holders like MOH, Development partners, Health Monitoring Unit (HMU), uniformed personnel and civil society. Sub committees were also set up at various levels for the smooth running of the programme e.g BCC, Operations, Logistics subcommittees. District and sub-county task forces were also formed to this effect. The Global Fund (GF), Presidential Malaria Initiative (PMI)/Department for International Development (DFID) and World Vision are among the development partners that contributed funds for the procurement of the nets and the various activities like registration and distribution. The Government of Uganda also contributed 10% of the funds for the distribution activities. Health Monitoring Unit then called Medicine and Health Service delivery Monitoring Unit (MHSDMU) was monitoring the process and field operations. METHODOLOGY The role of HMU was to provide independent monitoring of the MOH implemented LLIN campaign. HMU was part of the planning process in which guidelines, tools and the data management plan were developed. HMU was represented on the NCC which was responsible for the oversight of the entire exercise. The Unit also had representation on the BCC committee which was responsible for the Communication strategy of the campaign. HMU accessed funds from Malaria Consortium upon approval from MOH to carry out its monitoring activities. Additionally, HMU was one of the action centers 5 P a g e

6 receiving and addressing complaints through the mtrac SMS anonymous platform and the toll free number. Data collection tools and photography were used to capture information during registration, storage and distribution. The monitoring was mostly field based and involved teams going out to randomly selected districts to monitor the aforementioned activities. District task force officials and LLIN teams were also interviewed by the HMU teams. Further more access to information from various stake holders like MOH, Malaria Consortium, Kuhen and Nagel, UPF, UPDF was sought and granted. Where practical, the HMU teams attended either district meetings or trainings. HMU also attended the NCC meetings at central level during which the progress and key issues of the LLIN campaign were deliberated. A final report was made by HMU and submitted to MOH. The whole program was supposed to be government led and the partners were to support the process. FINDINGS PLANNING, CONTRACTING PROCESS AND TOOLS DEVELOPMENT The planning process for the LLIN Universal campaign in Uganda started in 2012 with submission of proposals to Global Fund. Global Fund confirmed a Grant of 15 million nets (Fund value to be obtained. In addition, the country received support from The UK government and The US government; through DFID AND The President s Malaria Initiative (PMI) by providing funds to procure 5 million nets. Another Key Partner was World Vision which donated 5000 nets for Wave 1.It also facilitated the distribution of 5000 nets in Eastern Uganda. The total nets that were to be distributed were 21 million. In 2013 when the final implementation planning process began, HMU learnt that a precondition had been set that the finances for the campaign be handled by a contracted organization other than The Government through the Ministry of Health. The reason was the lack of accountability in Global Fund phase 1. The initial award process for the said organization was marred with a general lack of clarity on the process and allegations of 6 P a g e

7 lobbying. This led to a new inclusive process being initiated and Malaria Consortium was selected for the Task. A Memorandum of Understanding was developed and after delays which at some point became a rate limiting step, it was eventually signed by MoH and USAID/PMI/Malaria Consortium/ John Hopkins University (JHU). The first implementation guidelines that were partly used in Wave 1 after the Launch limited government involvement and mostly provided for CSOs to carry out distribution. Security was to be hired including from Security firms. Government structures at both the Central and Local level would not be used extensively and data would primarily be handled by Non Government Agencies. The explanation was that accountability and less than desired outputs had been realized in Phase 1. The Minister of Presidency called meetings with multiple government Agencies including MoH, UPF, ISO, and UPDF to address the above concerns of modalities of registration and distribution process. It was agreed that Government structures would be used in the Campaign including exclusive data management, provision of security and taking lead in distribution. The Final Implementation guidelines were then developed by a selected representative Task Force in which HMU was part to include recommendations from the above meetings. Subsequently, other supportive tools that were either reviewed or developed included the Training Manuals, Communications Strategy and Plan, Data collection tools, Operational tools among others. COORDINATION & OPERATIONAL FLOW A functional coordination mechanism was a crucial component in ensuring success of the Universal LLIN Campaign stretching from the central level and down to the local government level. The highest coordination level was the NCC which had representation from various stake holders including MoH, USAID, DFID, SMP, HMU, WHO, Malaria Consortium, UPDF, UPF, PWC and Civil society. 7 P a g e

8 The NCC was chaired by Dr. Jane Ruth Acheng The Director General MoH and it was mandated to ensure successful implementation of the entire campaign. Primarily it provided oversight of the exercise meeting once a month to discuss the progress and challenges of the campaign. The meetings were irregular at the beginning of the exercise but in some months, they were even more frequent than what was prescribed to address issues. Minutes of these meetings can be accessed from MOH. In order to effectively implement the guidelines and improve efficiency, the NCC created three sub committees; The Logistics, Operations and BBC sub-committees. The Logistics sub- committee This committee was tasked with monitoring and ensuring smooth running of the Nets logistical chain. This including monitoring the freight, warehousing, transportation, storage at sub counties, delivery of nets to the distribution sites and withdrawal of balances. A number of challenges were noted as later detailed in this report especially in transportation, interchanged deliveries to distribution points, theft of some nets at Sub-county and distribution sites and the insufficiency of nets for the last wave (Kampala and Wakiso). In spite of the challenges, this committee is commended for the completing the huge task of managing logistics of such a huge magnitude as required by the Universal coverage campaign. The Operations sub- committee This committee was tasked with the functionality of the various aspects of the campaign. It was responsible for micro planning, organization, documentation, meetings, and stakeholder engagement among others. It was responsible for M&E of the exercise in regard to pre-determined indicators, data collection and report writing both progress reports and the final report. Many challenges were faced by this team such as coordination of the various stakeholders and operations, most of whom were field based.. There was a gap felt by the inability of the committee or its chair to take some decisions or answer some queries. In this regard, central coordination was weak. 8 P a g e

9 Data entry and management also posed a big challenge during the campaign but more so in the first half of it. Initially, a budget did not exist for this activity as it had been proposed to be managed by non-government agencies. A strong recommendation came from Government that the magnitude of data being collected warranted a more cautious and sensitive approach like user and access rights. VHTs and Community Resource Persons would collect the primary data, which would subsequently be transferred to the district then Resource center - MoH for data entry and storage. A budget was developed and approved although it was managed by SMP. Data entrants were recruited by the later in December 2014 almost six months after the campaign had started. They had a contract of 6 months which was insufficient to conclude the task. Behavioral Change Communication committee This committee was tasked with communication, advocacy, social mobilization and the media strategy. At the very start, it developed a BCC strategy/plan and budget to ensure sufficient mobilization for the exercise and promote use of the distributed nets. An official from HMU was selected as a member of this committee. Probably this committee performed the least in comparison to the former two. Although a new budget was developed and approved following the review of the initial guideline, it was not implemented as approved. The committee had no say over selection of best media options/houses and methods to use as they were informed decisions and tenders were awarded before the composition of this sub-committee. Funds and this component of the campaign were managed by SMP. In one meeting, the Sub - committee members present decided to resign to avoid being held responsible for implementation of the BCC component, which they were in essence not doing. This was communicated to the NCC but no conclusive action was taken. BCC progress reports to the NCC were subsequently either not made or made on their behalf. 9 P a g e

10 At the local level, mobilization was poor in some places as is detailed later in this report as some strategies in the guidelines were not implemented. At the district level, the district coordinators and supervisors were responsible for overseeing all the activities related to registration and distribution including management of preliminary data at the district level. The district coordinators were employees of Malaria consortium while the supervisors were employees of MOH. They were the interface between the center and the district. They worked closely with the district task force members to ensure smooth running of the activities although there were incidences were RDCs and DPCs complained of not being aware of nets arriving in their districts. In Arua district, there was good team work between the RDC, the district coordinators and the HMU team. This good coordination was also observed in Koboko district where the DISO, RDC, LCV chairperson and MP worked closely with the LLIN teams in ensuring the exercise went well. The DISO of Kibuuku was also heavily involved in the distribution exercise. In Kibaale, both the political heads and religious leaders participated actively and worked well with the district LLIN teams. Political heads were also actively involved in Butambala district. During the debrief meeting, the DHO Kirihura reported that his office and that of the malaria focal point person were not informed of the arrival of nets in the district. The majority of district task force members complained that they were not facilitated with fuel to effectively do their work of supervision and monitoring. The majority expected to be paid a stipend meaning this was not well explained during the entry meetings or trainings. Some also complained that they were not privy to the budget and questioned the inclusion and exclusion criteria of payment of various categories of people involved in the exercise. The sub county supervisors, health assistants and community development officers provided another level of coordination with the community through the VHTs and LC1 chairpersons. Despite complaints of little pay, the VHTs in most parts of the country worked tirelessly to ensure this the exercise went according to schedule. The HMU teams would attend some of the evening meetings that the district coordinators and supervisors held with the various sub county supervisors on the registration and distribution days. In these meetings, each sub county supervisor gave a situation report 10 P a g e

11 of the day s activities. This was an effective way of identifying cross cutting successes and challenges which would then be forwarded to the subcommittees or NCC. LLIN teams briefed the politicians and technocrats before exiting the district during both the registration and distribution phases. They presented the data on individuals and households registered and the nets distributed. It was also an opportunity to respond to complaints raised by the various stakeholders. Although, there were various challenges related to coordination like untimely communication and fuel for district task force officials, the various levels of coordination ensured that various activities of the LLIN campaign were functional. HMU endeavoured to attend exit meetings or sub county supervisor briefs e.g in Kirihura, Arua, Rukungiri, Mbale and Nebbi. TRAINING Training manuals were developed at the central level and these were used to train the NCC, district supervisors and coordinators, sub county supervisors, the district task force (DTF), the sub county task force and the VHTs. At the central level, the NCC members were oriented on the general objectives and methodology of the programme and the terms of reference of the NCC. The district and sub county supervisors were also trained at the central level in regard to the programme objectives and their roles. The sub county supervisors then proceeded to the districts to train the district and sub county task forces District task forces were constituted and they included the RDC, CAO, LCV chairperson, DPC, DISO and DHO. The training included terms of reference and overview of the LLIN programme. Subcounty task forces were also constituted and trained regarding their terms of reference, registration and distribution criteria. They included the Community development officers (CDO), the health assistants and sub county chiefs. The CDOs and health assistants conducted trainings of the VHTs and the LC1 chairpersons on registration and distribution criteria. Trainings of VHTs and LC1 chairpersons lasted two days and it preceeded the registration exercise In the case of Kampala and Wakiso, Kampala City Council Authority (KCCA) availed 1000 VHTs to carry out the exercise of registration and distribution. This was contrary to the agreed position of the NCC to use nurses and uniformed personnel. Despite the fact that 11 P a g e

12 the KCCA VHTs had previously engaged in similar activities of public health nature, the outcome of the registration and distribution in Kampala and Wakiso was poor compared to other parts of the country. One of the factors attributed to this could be the poor training of the KCCA VHTs in regard to the LLIN campaign. The HMU team attended training of trainers (TOTs) sessions in Kisoro and Kabale and the exercise was conducted well in the different sub-counties. The VHTs and LC 1 chairpersons were trained for two days prior to registration The training content included registration and distribution criteria, malaria status in sub counties, the role of LLINs in malaria prevention, how to hung up nets, dates of bed nets registration and key messages to LLIN users. In general, it was observed that trainings took place at the various levels in order to high light the objectives of the programme, terms of reference of various task forces and the guidelines for registration, distribution and LLIN usage. However, as will be shown in the registration and registration subsections, some of these guidelines were not followed either due to shortage of man power, local political pressure, individual incompetence, favouritism and poor planning. The data supervisors and entrants were trained on data management, data structure, inventory and analysis. Demonstration of net use in Nakalama parish and Gomba subcounty in Butambala district 12 P a g e

13 STORAGE The designated areas for storage of the mosquito nets within districts were sub county head quarters. District Task Forces (DTF) worked with the respective sub county chiefs to find suitable storage space for the LLINs at the sub county head quarters. In areas with inadequate or dilapidated storage, alternative storage was found at either health facilities, schools or at the RDCs offices e.g in Wanale subcounty, Mbale district where they were stored at a health centre and in Budaka town council, Budaka district where they were stored at the RDCs office. Bales in secure sub county stores in Kyankwanzi and Mpigi districts In all the stores visited, they were relatively well aerated, lockable and not leaking. One common observation was lack of pallets in all stores. Security was provided either by the police or locally hired vigilantes. Nets were mainly stored at sub county stores while in some areas, they were stored at nearby health facilities. 13 P a g e

14 Police personnel guarding Kiboga town council stores REGISTRATION The registration exercise was conducted prior to the distribution exercise and was done per wave. It was intended to provide a list of households and number of persons. Two VHTs were assigned to one village and captured data using household registration forms. The exercise lasted on average 2 days although there were pre-registration activities like deployment of the teams and interfacing with the local political hierarchy. It was followed by the actual registration and allocation exercise. The registration was scheduled on the weekends to cater for residents who are not at home during week days. The HMU teams observed that the compliance of communities to register improved over the subsequent waves. Low compliance was probably due to the low publicity at the beginning of the exercise. Districts that received nets in the earlier waves acted as testimonies that nets were being distributed. In general, the registration went on well in most districts with 100% registration in some villages as evidenced by no complaints on distribution day. Registration problems were mainly due to insufficient time budgeted for registration, deliberate refusal to register, errors by VHTs, provision of inaccurate information by household members, local political interference; and migration of people between time of registration and distribution. The latter happened mainly in waves 6, 7 and 8 when there was a time lag between registration and distribution. 14 P a g e

15 In some districts like Arua, the task force officials complained of lack of facilitation and were reluctant to participate on the actual day of the exercise. However, they attended preparation meetings with Malaria Consortium officials. They therefore did not monitor registration in most areas, hence its failure. Many people missed out on the registration especially in the sub-counties of Dadam, Ajia, Uleppi, Okollo, Katirini, Rhino-Camp and Arua Municipality. In Uleppi, the community complained that VHTs did not conduct the actual registration on ground but they relied on the old registers for the Neglected Tropical Diseases (NTD) to conduct the registration. In Okollo sub-county, Rhino Camp and many other sub-counties, the respondents complained that the VHTs and LC 1s were selective in the registration exercise, preferring to register mostly friends and relatives, while in Manibe, the VHTs prioritized registering children than adults. Cases of selective registration based on political affiliation, social rivalry, tribalism and extortion were also observed. In Muduma subcounty, 10 Ugandans of Rwandese origin claimed their houses were deliberated skipped by the LC1 chairperson during registration, an allegation he denied. In Kijayo Village, Muteme Parish, Kiziranfumbi subcounty in Hoima district, the LC1 chairperson charged every household 1,000 shs for registration. He ordered the VHTs not to register those who did not comply. It was only after HMU s intervention that households in the village were finally registered on the 9/2/2014 and he was forced to refund the money he had collected from some of the households. Misinformation and poor sensitisation was observed in some areas, e.g a predominantly Moslem community in Nakigo sub county, Iganga said it was against their faith to use nets. HMU worked with the sub county supervisors to try and sensitize the community. In Kiziranfumbi sub county, Hoima district some farm workers were left out at the beginning of the registration exercise simply because they did not belong to households. HMU intervened and asked the VHTs to register the farm workers since they resided on the farm. There were cases of VHTs traversing the communities to register residents but instead stationed at their personal homes for residents to come and register. This was observed in some cells in Kisoro town council. 15 P a g e

16 Number of households registered 8,322,706 Number of people registered 39, o Pregnant women 1,166,051 o Children under five years of age 9,647,631 Total households registered 8,322,703 Number of LLINs allocated 21,772,356 DATA ENTRY The data handling and management team was hired through a process of advertising and short listing by JHU/SM. They were given a contract of six months effective December The team included 13 data entry supervisors, 4 data managers, 2 system administrators, 11 data recovery and verifications officers; and 2 cleaners. The data team underwent training at various levels and this included introduction to the operating system of the data management, data structure, inventory and analysis. The 120 data entrants had to be divided into two groups with one working day shift and the other working evening shift. This was to prevent the system from being overwhelmed by 120 entries at any single time. Initially, they had been hired for 6 months until June 2014 but a 3 months extension was done to complete Kampala and Wakiso entries. Preliminary data capture began at field level by the VHTs using household registration forms. Two VHTs were assigned to one village to collect this data. These household registration forms were then picked by the sub county supervisor, CDO or HA who would in turn forward them to the district coordinator/supervisor. Summaries of this data were also entered onto village, parish, sub county and a district summary form. Allocation, a process of computing the number of nets needed per house hold, village, parish, subcounty and district was done by the sub county supervisors, CDOs, HAs and district 16 P a g e

17 supervisors a day after registration. A soft copy was sent to MOH for clean up. The transporters would also receive a final copy of the allocated nets per sub county. Data authentication was done at various levels of the handling process. The main levels of verification were during allocation and during data clean up in Kampala. Any queries were reported back to the field teams and the necessary adjustments done. It was observed that errors mainly occurred during computation of nets needed versus number of household members. The software used for data entry had access levels to prevent unauthorized access or alteration of data. Data entrants could not alter any forms that had been entered into the system. All data including Kampala and Wakiso, as of October 2014 had been entered into the system. The hard copies were left at the RDCs or DISOs office until after the distribution exercise. They were taken to Kampala and are temporarily stored in a rented MOH facility in Kampala whose contract expires in November The NCC has to find alternative storage space for the hard copies. MOH reports that they intend to keep the hard copies for a minimum of eight years in conformity with guidelines for management of raw data. One of the main challenges during data entry was the small capacity of the server. The more data entered, the slower it became and this affected the entire process of data entry. A proposal to procure a bigger capacity server for data storage and future use has been submitted but this is subject to availability of funds. POLITICAL PARTICIPATION The participation of politicians was observed at various levels of the entire exercise. This greatly supported the function of the technical teams and helped in mobilizing the community. At the district level, LC1 and LC111 chairpersons were involved in the exercise and despite a few challenges as mentioned earlier, their participation is highly appreciated. 17 P a g e

18 LC111 chairperson (extreme right) addressing community members who had missed out on receiving nets amidst protests at Lubango parish Some LCV chairpersons directly participated in the exercise while others delegated their roles. HMU observed that most members of parliament did not take a keen interest in the exercise especially in their districts. The Youth Member of Parliament for Northern was heavily involved in monitoring the distribution activities in Koboko district. At the central level, the Minister and State Ministers of Health followed the proceedings of the entire LLIN campaign and provided political support where necessary. His Excellency, the President of the Republic of Uganda, took a keen interest in this programme right from its inception to the end. As mentioned earlier, he participated in the launch of the programme in Soroti district, and then the final distribution of nets in Kampala in August P a g e

19 His Excellency, the President distributes a mosquito net in Kampala flanked by Primeminister, Dr.Ruhakana Rugunda (centre) and State Minister for Health, Dr.Elioda Tumwesigye (left) TRANSPORTATION Kuhen and Nagel were the appointed forwarders of the mosquito nets from the countries of manufacture to Uganda. The tendering process was done by the Global Fund head office in Geneva. K&N report that they did not encounter any losses during freight of the nets to Uganda. Upon arrival, the mosquito nets were stored at the designated warehouses in Kampala before being dispatched to the field. Globetrotters, were subcontracted by K&N to transport the nets to the sub county stores. Although MOH would provide loading data to K&N prior to the loading in Kampala, HMU teams observed that some sub counties received either less or excess nets on the waybill vis avis the amounts generated at registration. The amounts varied from between 2 to 5 bales. Globetrotters acknowledged that these errors were at the loading stage of the trucks in Kampala; the necessary adjustments were made. Nets were delivered in time to the sub county stores or other designated areas prior to the exercise and this was between one day to three weeks. Malaria Consortium then subcontracted Ballore Logistics to transport the nets to distribution sites on the 19 P a g e

20 distribution days. It was observed that some districts had poor availability of mechanically sound trucks. Some of the local contractors had few trucks and in some cases, one truck was used to make deliveries to several distribution points and this delayed onset of distribution. A case in point is Kaburasooke Subcounty in Gomba district where a truck was leaving the sub county store at 4.30pm to deliver bales to a distribution site where people had assembled since 9am. Citing security concerns during late distribution, the HMU team advised against the truck proceeding but rather differ it to the following day. In Buyende district, the distribution was delayed especially in Kidera sub county where some guarded bales were observed lying by the road side by 4.30pm due to inadequate transport. HMU intervened and local government truck was used to ferry the nets away. In Kamuli town council, Bunangwe zone, the supervisor was using a personal saloon car to ferry bales and this affected the amount of nets delivered to distribution sites hence delaying the exercise. In Namutamba district, 316 bales instead of 326 bales were delivered and on verification, the error had been made at loading in Kampala. The district coordinator was tasked to follow this up with the warehouse in Kampala.. Bales at sub county stores in Kiboga and Gomba (Kaburashoke) awaiting transportation to distribution sites at 1pm 20 P a g e

21 The transportation of nets in hard to reach areas also affected intra district distribution. These hard to reach areas included hilly districts and islands! Districts with challenging terrain include Mbale, Sironko, Bulambuli, Kween, Kisoro, Manafwa, Bududa, Bukwo, Kisoro, Kanungu and Kabale. Some of the roads were impassable and nets had to be carried by people to distribution centres affecting the distribution schedule. In Ruhehe, Kisoro district, and Wanale subcounty in Mbale, nets had to be carried on foot from the sub county headquarters to the distribution sites due to the hilly terrain. On the island districts of Buvuma, Kalangala and Namayingo, there was a challenge of transporting the nets by boat to the smaller islands. Kalangala district is made up of eighty islands and this posed logistical and distribution challenge. This was the same for Buvuma district which has about fifty islands. There was also the problem of off loading and unloading at the landing sites. The transportation of the UPDF to and from Bugoma (Kalangala ferry port) about 45kms away & deploying them to the sub-counties on the main island was a challenge. The sub county supervisor of Muduma in Mpigi district loads bales into a van to replenish nets at a distribution site 21 P a g e

22 DISTRIBUTION A distribution site in Amuru district In order to attain universal coverage, one net per two persons was the distribution criteria. The success of the distribution excess varied across the country. It was observed that the outcome of the registration exercise and the involvement of the district leadership had a significant impact on the distribution exercise. Some distribution teams had divided the distribution sites into villages/cells for ease of distribution and this made the exercise smooth and organized. Rowdiness in some areas was due to delay in onset of distribution, being absent on the lists, favouritism and most importantly; lack of adequate security. 22 P a g e

23 VHTs pose for a group photo (left) and verify names of net beneficiaries at distribution points in Gomba district In Arua, the RDC and his team were heavily involved in the distribution exercise despite the launch of Elimination of Mother To Child Transmission (EMTCT) in the district which was a parallel but equally important programme. Distribution was successful in the subcounties of Okoro, Uleippi, Katrini, Aivu, Ogoko, Pajolu and Arua Municipality. Anyiribu and Oluko sub counties had minor issues of misallocation but these were addressed and people received their nets. In Kisoro the RDC, DISO, LC5 and CAO were fully involved in the exercise and they ensured the activities went according to schedule. In Namayingo district, nets were not delivered by the 2 nd day and this had caused anxiety and restless among the youth. HMU intervened and nets were delivered on the third day. Distribution of nets on the island districts like Buvuma and Namayingo was delayed due to late deliveries. In Katiira sub county, Budaka; a VHT took it upon himself to register 37 households on the day of distribution and distribute 98 nets. Though he provided the accountabilities, this is against the distribution guidelines. This was the same case in Kangulumo zone, Namutumba district where the LC1 Chairperson also distributed 34 pieces to unregistered people. Initially in wave 2, it was thought that the balance of nets were to remain in the districts and be redistributed to schools, pregnant mothers and health facilities. However, this was later revised and nets were to be brought back to the centre by district coordinators and supervisors for repackaging. 23 P a g e

24 Well organized distribution points in Kyankwanzi district In Kasenyi Parish in Buseruka S/C and Bujumbura Division in Hoima Municipality some people who claimed they were registered report not receiving nets at all. Late distribution was noted in the rift valley region in Buseruka because of the bad terrain. In central and north Parishes, Kagadi town council in Kibaale district, some people who claimed they were registered were missing on the register. In Butyaba, Biiso and Butyaba sub counties, there were also cases of many people who did not receive nets due to nonregistration. Unregistered people in the parishes of civic cell (Buliisa TC), Piida B (Butyaba) and Biiso (Biiso) were seen scrambling for nets at the distribution sites. In Gomba district, the HMU team came across two VHTs who had suffered from skin irritation caused by chemicals embedded in the nets. Universal coverage was achieved to a fairly great extent in Maracha district save for a few isolated incidences in Maracha TC, Nyadri SC, Oluvu and Oluffe. The District leaders participated in mobilization activities and were happy with the progress of the exercise. In Kyotera Town Council, Rakai district, VHT s and LC officials of two villages (Cell 13 and TDO) complained that the 5,000/- paid to them on the first day of the exercise was very little and did not turn up the following day. The Sub County supervisor had to hire a few untrained local residents to distribute the remaining nets. In Ntwetwe Sub County, Kiboga district, 120 registered people missed receiving nets due to under delivery of nets. After HMUs intervention, the district supervisor rectified the problem and more nets were delivered. 24 P a g e

25 Mothers receiving mosquito nets In Bushenyi, district FDC chairperson spread propaganda that the blue mosquito nets were are initiative of the FDC party and this caused confusion. HMU attempted to correct the issue through radio talk shows on the local radio station. In Bushenyi, Mbarara and Kabarole districts, it was observed that some of the 40-net-capacity bales were less by 3 to 5 bales. The explanation given by MOH and Malaria Consortium was few nets were removed from some bales and sent to NDA for quality control tests. In Kampala and Wakiso, the distribution criteria for universal coverage was adjusted to two nets per household. However, an extra net was given for households with a pregnant woman. This adjustment was due to an unforeseen shortfall in the number of nets available for the two densely populated districts. Even with this change in criteria for Kampala and Wakiso; the country would statistically achieve coverage of greater than 90%. Evidence also shows that the prevalence of malaria is lowest in Kampala district and stands at 6%. Secondly, there was also the assumption that the majority of households in the two districts had nets because of better purchasing power by the residents or through previous targeted distributions like ANC. It was also noted that in most places, the VHTs did not sensitize the community on the usage of LLINs and where they did, it was conducted in a hastily manner. 25 P a g e

26 A lady acknowledges receipt of her mosquito with the help of a VHT in Kampala BEHAVIOURAL CHANGE COMMUNICATION Behavioural Change Communication (BCC) strategy of the LLIN campaign was developed in the National Communication Plan (NCP) for LLIN and it mainly focused on net usage and repair. John Hopkins University (JHU) and Stop Malaria developed all radio spots and messages that were used in mass media campaigns on the radio. Bill boards were not erected during the early stages of the LLIN. Use of megaphones and loud speakers mounted on vehicles or motorcycles was not employed and yet it is an effective way of increasing awareness. MAAD was the advertising firm contracted for the BCC campaign and its contract ended on July Communication for Healthy Communities (CHC), a USAID funded project took over BCC activities in July 2014 and run through October They mainly focused on scaling up messages about LLIN use, care and repair on 67 radio stations across the country. 48 bill boards were erected across the country with a higher concentration in Kampala and Wakiso. 10,000 stickers on care and repair were developed in 17 languages and distributed across the country.. 26 P a g e

27 Billboards promoting net use at Mulago and Naalya round abouts in Kampala On the final day of net distribution in Kampala, CHC supported the media coverage for the closing ceremony as well as developing success story about the event.the HMU teams observed that radio talk shows about the LLIN campaign were conducted by LLIN teams or district task force members in most of the districts visited. The knowledge, attitudes and practices and the importance of the LLIN varied in different areas and communities. In Kibaale district, mass sensitization prior to exercise was poorly done and people complained that radio announcements were hastily done. A number of the people interviewed in civic cell (Buliisa TC), Piida B (Butyaba) and Biiso (Biiso) in Kibaale district noted that the mass sensitization prior to exercise was not well done with many expressing ignorance of the whole campaign. In Buhimba SC in Hoima, some beneficiaries of the nets were seen trading them for money and alcohol meaning sensitization about the importance of nets was poor. In Kisoro, the RDC and DHO had a talk show on radio Muhabura while radio spots were running through out the day. HMU secured an extra talk show on Voice of Kigezi for the DHO and radio spots run throughout the day. In some communities, it was common to see nets being used to fence small gardens as a way of keeping away domestic animals. In other areas, they were used as fishing nets in rivers and streams while some are used as football nets. It could not be readily established whether these were nets of the Universal LLIN campaign or from previous distributions. The fact that nets are used for these purposes necessitates the 27 P a g e

28 strengthening of the BCC element in order to improve knowledge, attitudes and practices regarding mosquito nets. In Wave 4 and 5, HMU conducted radio talk shows on Radio West in Mbarara, Voice of Tooro in Kabarole and Heart Fm in Mubende. This was aimed at increasing awareness about the objectives of the exercise, methodology of distribution; and getting community feed back. In Masaka town, mobile public address systems mounted on vehicles were used in mobilization for the medical male circumcision (MMC) and it proved a more effective publicity tool compared to the LLIN campaign that was going on at the same time. Video coverage by CHC of the LLIN distribution exercise in Kampala SECURITY AND PRESENCE OF THE ARMED FORCES Provision for security was a prerequisite during the entire the exercise and was meant to be available during transportation, registration, storage and distribution. This involved use of policemen, local vigilantes and the UPDF; and this had been budgeted for. The representation of the Uganda Police Force and the UPDF on the NCC was to help in coordination of security matters. This was in liaison with the existing district security structures. At the district level, the security of the LLIN programme was overseen by the district security committee chaired by the Resident District Commissioner (RDC) and 28 P a g e

29 included the District Police Commander (DPC) and the District Internal Security Officer (DISO). Terms of reference of the Police included provision of security, distribution of nets and investigating theft of nets while that of the army was mainly security and distribution. In areas where the UPDF had bases, divisions or units, they were supposed to take the lead role while in areas with no UPDF presence, the Police was meant to take the lead role. The Police did not participate entirely in wave 1 but it was rather the UPDF that took the lead. However, in general, the Police played a bigger role than the UPDF in the exercise because of the logistical challenges face by the latter. The Police delegated the responsibility of verification of recipients of nets to the DISO structures and the LCs. O.C station Luuka district (in white trousers) on inspection of the exercise at Buwologoma distribution site Some DPCs, RDCs and DISOs participated actively in the exercise. The DPC of Butambala moved monitored the exercise in his personal vehicle despite no operational funds. The RDCs of Buyende and Koboko, the Mayor of Mukono and DPC of Mbale were also actively involved in the distribution exercise. However, some DPCs and RDCs reported that they were not informed in time or at all about delivery of nets to the districts and this affected the deployment of personnel. 29 P a g e

30 The presence of security personnel on the ground was thin. Some trucks were not accompanied by security personnel neither were some stores guarded. Community volunteers sometimes guarded the storage facilities. Police and UPDF personnel were not visible at most of the distribution points while some sites were manned by only one policeman. This made enforcing order and crowd control difficult. At a distribution point in Budaka town council, a single policeman couldn t do much as the crowd became very restless and disorderly. It was observed that security personnel were deployed on the day of distribution and this meant some reported late for duty. In Budaka, security was mainly provided by members of the reserve forces. In Kiruhura district, both Police and crime preventers participated in keeping law and order during the distribution exercise. Lack of coordination between the LLIN district supervisors/coordinators and the security teams caused delays in deployment or lack of deployment at all in some districts The presence and roles of the UPDF as stipulated in the guidelines was not visible in most of the districts. However, in the districts where the UPDF was present, it was more of guard duties than actual distribution. This happened in Kyankwanzi where their presence was very visible but more in guarding roles. In Butambala district, there was a UPDF soldier at Kibibi sub county distribution site, but more in a guarding role. In Kalangala district, 50 UPDF personnel were deployed as guards in addition to the 63 from the Uganda Police and Prisons bringing the total number of uniformed personnel to 113. In Wanale Sub County in Mbale, two UPDF soldiers were deployed at the Bubentsye distribution site. 30 P a g e

31 Uniformed personnel guarding distribution sites in Kiboga (L) and Masaka districts (R) THEFT OF NETS Across the country, the distribution chain of the LLINs went on smoothly but there were isolated cases of loss of nets either due to theft or negligence. Thefts mainly occurred on the distribution day during loading from the stores, transportation to sites and during off loading. Deliberate losses were caused when local area politicians coerced the VHTs to distribute nets to unregistered people.hmu was involved directly and indirectly in monitoring the cases of net thefts but due to the vast coverage of the exercise, it mainly limited its role to follow up. Thefts were mainly due to inadequate security, poor sensitization and occasionally poor coordination amongst various stakeholders like security and LLIN teams. In Kibaale. the district task force members complained of having not been consulted before the exercise and they attributed the thefts to this. Follow up of these cases by local Police in some areas was inconclusive due to logistical challenges. In Luweero district, 14 bales went missing between the stores and distribution point. The district supervisor reported the matter to Wobulenzi Police station and the sub county supervisor was arrested. HMU joined the investigation and recovered the 14 bales in a guest house in Wobulenzi town council. The case is before court. 31 P a g e

32 In Mityana town council, 23 bales and 26 nets were stolen. The case was registered at the Mityana Police station by the sub county supervisor and investigations are ongoing with the help of HMU. In Idudi subcounty, in Iganga district, 8 bales were stolen. HMU intervened and the suspect who was involved in registration was handed over to the police. The 8 bales were recovered and returned to the store. At the Bulanku sub county stores, 10 bales went missing from that had been accessed by the LCIII chairperson. The DPC was reluctant to follow up saying he unaware of the presence of nets in the district. At the same sub county store, a volunteer who was loading nets stole one bale. In Budumba sub-county in Bududa district, a bale that had fallen off a truck was recovered from a boda boda cyclist and handed back to the DISO. In Bubiangu subcounty in Mbale district, 2 bales were stolen from the subcounty stores but 34 nets were later recovered by Police. In Industrial division in Mbale, one bale was stolen during transportation and the suspect was arrested by police. In Bulonge sub county, Namutamba district, 12 bales were stolen from the sub county stores under the LCIII chairperson s overall custody.10 bales under the custody of the CDO were also lost enroute to the distribution point. The cases were reported to the local area Police post. In Makemba village, a local area councillor incited the public by saying all people at the registration sites were entitled to nets and 2 bales were grabbed by unregistered people but 1 bale was letter recovered. In Namutumba town council, 1 bale was stolen by a mob after they assaulted a VHT following incitement by the LCIII chairperson. In Nabinyonyi village, Magada sub county, 2 bales were stolen by the LC1 chairperson but they were recovered after his arrest. In Amika parish, Arivu Sub County in Arua district, 37 pieces were stolen by the health assistant and the askari. HMU participated in the investigations and the 37 nets were recovered and distributed to those who had missed. In Mpefu sub county, Kibaale district, 12 bales destined for Rutoma parish were stolen and the matter was reported to Kagadi Police station. The district supervisors and coordinators improvised by using balances from other areas. 32 P a g e

33 ACCOUNTABILITY AND PAYMENT OF ALLOWANCES Funds were allocated for different activities of the LLIN campaign. Procurement of nets and transportation of net services were done at international level. Different development partners like DFID, PMI, Malaria Consortium, the Global Fund and GOU funded different activities of the campaign. Other Payments were made for trainings, hire of supervisors and coordinators, hire of data entrants, data entry, procurement of the server, procurement of inland transportation services, facilitation for monitoring teams, launch and closing ceremony of the LLIN campaign etc. Price Water House Coopers (PWC) was the local fund agent (LFA) responsible for auditing activities and accounts for the entire LLIN campaign, hence the detailed audit reports can be accessed from them. HMU mainly focused mainly on verification of payments made to field teams like VHTs, CDOs, HAs, LCs and uniformed personnel. There was a standard payment structure for various personnel. The standard for VHTs was 5,000/= per day for 3 days of registration and 2 days of distribution. They were also to paid 5,000/= for a one day training. LC1 chairpersons were only paid for the one day training and not registration or distribution. CDOs and HAs were paid 37,000/= for every day worked while store managers were paid 15,000/= per day for 3 days. A flat fee of 100,000/= was provided for security at the sub county stores. District and sub county supervisors were paid 100,000/= per day as per diem and 80,000/= per day as honorarium while district coordinators were paid 96,000/= per day. 200,000/= as a lump sum was budgeted for the district task force for coordination and monitoring. 150,000/= was budgeted per sub county for off loading. In Kampala and Wakiso, four VHTs were assigned to a village and they were paid 12,000/= per day worked.hmu received funds for monitoring the activities of LLIN campaign through Malaria Consortium. Although HMU was not involved in wave 2 activities, it was reported that all UPDF personnel were paid. In wave 2, all Police personnel who participated were paid except those who worked in Mbale, Budaka and Namutumba districts. All Police and UPDF personnel performing guard duties in the subsequent waves were paid. However, no payments have been made to date for facilitation of DPCs. Most of them drew fuel on 33 P a g e

34 credit to help in monitoring during distribution. This has been brought to the attention of MOH but no positive feedback has been given to the DPCs as reported by the Police focal point person on the NCC. The district coordinators and sub county supervisors acknowledged having the necessary resources to pay their teams although there were incidents of delayed processing of field facilitation for VHTs and sub county supervisors during wave 6 but the funds were later received. There seemed to be variations in amounts that were paid to the same cadres within a district or between districts but this mainly arose in situations where money meant for one person was split between two people. In the spirit of transparency, some district task force members had requested for a copy of the payment schedule for but this was not done. Most VHTs reported they were not sure of their rates during the different exercises of the LLIN campaign. They reported receiving 10,000/= during training, 5,000/= per day for the 3 day registration exercise and 5,000/= per day for 2 days of distribution. This tallied with the payment schedule of the LLIN campaign. There were also variations in amounts paid to guards, CDOs and health assistants in some districts. Despite 100,000/= being allocated for guards at sub county stores, some guards were paid 90,000/=. A case in point is Kadama sub county stores where the police guard was paid 90,000/=. The sub county supervisor could not give a valid explanation as to why she made payments less by 10,000/=. The store manager of Kadama sub county store was paid 13,000/= per day for 3 days as opposed to a total of 15,000/=. The supervisor was asked to present an accountability report but this never happened. It was also observed that payments through third parties were made especially in the case of uniformed personnel. In some districts, money meant for guards was paid in bulk to DPCs so that that they would in turn make the payments to the junior staff. However, this third party payment is against best accounting practices since it could not be readily established whether the primary receipients received their money as scheduled. 34 P a g e

35 GENERAL OBSERVATIONS In general, the communities were thankful to the government for the mosquito nets. The use and involvement of government structures contributed to the success of the campaign. The NCC was very strong, professional, all inclusive and committed and this provided the strong oversight needed for the campaign. In 2013, there was a stalemate due to disagreement on the standard criteria of the LLIN nets to be delivered. Nets are usually assessed based on area of coverage, suspension height, type of fabric, size of holes, number of holes per square meter and bursting strength. WHO has standard criteria although some countries may in addition have more specifications. The impasse was later resolved and the nets were cleared by Uganda National Bureau of Standards although this had already caused delays and bad publicity. Sensitization before and during the LLIN campaign was very poor and this was strongly attributed to a weak BCC component. Trainings were conducted at various levels and this contributed to the success of the campaign. However, it was observed that some of the LC1 and LCIII chairpersons who represented the political aspect of the campaign had conflicting ideas during the registration and distribution. As indicated above, some LC1 and LCIII chairpersons abetted the acts of theft and illegal distributions. VHTs that worked in challenging terrain or in more cosmopolitan communities got the same allowances across the board and this was unfair. VHTs in most districts could not easily be identified because they lacked t-shirts or aprons. There was poor coordination between the mainstream LLIN taskforce and the uniformed personnel and this affected deployment and participation of the uniformed personnel in most of the districts. 35 P a g e

36 The registration exercise in some districts especially Kampala and Wakiso was poor leading to poorly updated registers. Some of the LC1 chairpersons attributed this to lack of proper training of VHTs. District task force members in most districts cited lack of fuel facilitation to monitor the exercise although the LLIN coordinator reported that lump sum facilitation was provided to the task force. There were some logistical and administrative bottle necks like shipping delays and clearance by NDA. These caused delays in the distribution exercise especially in wave 5, and 7. Though there were checks and controls for the data captured, the efficiency of the data entry and storage process was hampered by the inadequate capacity of the server. It is not clear why a new server for such a huge project was not procured before the exercise. Facilitation of the uniformed personnel was mainly in the initial wave in the East and the UPDF and Police report that their personnel involved in subsequent waves were never paid their allowances. Individual officers also stood in for the ministry of health in securing fuel from petrol stations and have had to refund using their own money. Coordination between the LLIN teams and the uniformed personnel was poor and this affected the planning of deployments. As mentioned earlier, the deployments were either late or absent. There have been reports of disparities in payments made to the various transport service providers of the LLIN teams but these could not be confirmed. Loss of nets occurred mainly during transportation, offloading and registration. This was due to negligence but mainly due to thefts. Attempts to get the total number of cases of net thefts reported to the Police in different districts have been futile. 36 P a g e

37 The registration and distribution exercise in Kampala and Wakiso districts was poor compared to the rest of the country. There was a deficit in available nets and the implementation of both exercises was poor. Some households sampled in Rubaga, Naguru, Kiwatule, Kawempe, Makindye and Kira town council did not receive nets. RECOMMENDATIONS 1) The strong involvement of the political wing at various levels is good and this strategy should be employed during future similar programmes. 2) The success of this programme can partly be attributed to the fact that it was implemented through existing government structures and this strategy should be employed during future similar programmes. 3) Much as BCC was part of the implementation strategy, it should strongly be implemented before, during and after the exercise. This will help in improving the knowledge, attitudes and practices. The BCC task force and those concerned should explain why this component was weak and whether there was value for money. 4) During training at the grass root level, the politicians like LC1 and LCIII chairpersons should be advised to desist from politicizing or personalizing the exercise. 5) There should be timely coordination between both field and central LLIN teams; and the uniformed personnel in order to effect timely deployment. 6) In order to prevent delays in release of nets, NDA s capacity to handle a large volume of nets should be improved. 7) Given the size of data of such an exercise, similar programmes in future should be provided with servers commensurate with such a work load. 8) In future, country specifications of LLINs should readily be availed by UNBS not only for bulk government or donor procurements but also to URA and the public. 9) All outstanding payments to service providers or entities that were involved in the LLIN campaign like the uniformed personnel and HMU should be made. 37 P a g e

38 10) An audit should be done into funds allocated for payments made to VHTs, health assistants, uniformed personnel, CDOs, store guards, district task forces, sub county teams, transport providers and the BCC component. 11) The audit report and recommendations by the Local Fund Agent should be consulted and the recommendations implemented....malaria continues to kill nearly a million people a year world-wide, and by far the single most reliable protection against malaria is to sleep under a mosquito net... (Michael J. Behe) 38 P a g e