Design, implementation and evaluation of a national campaign to deliver 18 million free long-lasting insecticidal nets to uncovered sleeping spaces in Tanzania

Abstract

Background: Since 2004, the Tanzanian National Voucher Scheme has increased availability and accessibility of insecticide-treated nets (ITNs) to pregnant women and infants by subsidizing the cost of nets purchased. From 2008 to 2010, a mass distribution campaign delivered nine million long-lasting insecticidal nets (LLINs) free-of-charge to children under-five years of age in Tanzania mainland. In 2010 and 2011, a Universal Coverage Campaign (UCC) led by the Ministry of Health and Social Welfare (MoHSW) was implemented to cover all sleeping spaces not yet reached through previous initiatives.

Methods: The UCC was coordinated through a unit within the National Malaria Control Programme. Partners were contracted by the MoHSW to implement different activities in collaboration with local government authorities. Volunteers registered the number of uncovered sleeping spaces in every household in the country. On this basis, LLINs were ordered and delivered to village level, where they were issued over a three-day period in each zone (three regions). Household surveys were conducted in seven districts immediately after the campaign to assess net ownership and use.

Results: The UCC was chiefly financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria with important contributions from the US President's Malaria Initiative. A total of 18.2 million LLINs were delivered at an average cost of USD 5.30 per LLIN. Overall, 83% of the expenses were used for LLIN procurement and delivery and 17% for campaign associated activities. Preliminary results of the latest Tanzania HIV Malaria Indicator Survey (2011-12) show that household ownership of at least one ITN increased to 91.5%. ITN use, among children under-five years of age, improved to 72.7% after the campaign. ITN ownership and use data post-campaign indicated high equity across wealth quintiles.

Conclusion: Close collaboration among the MoHSW, donors, contracted partners, local government authorities and volunteers made it possible to carry out one of the largest LLIN distribution campaigns conducted in Africa to date. Through the strong increase of ITN use, the recent activities of the national ITN programme will likely result in further decline in child mortality rates in Tanzania, helping to achieve Millennium Development Goals 4 and 6.

Figure 1

Sequence of Universal Coverage Campaign activities at different government administration levels, mainland Tanzania. NMCP = National Malaria Control Programme; ITN = insecticide-treated net; UCC = Universal Coverage Campaign; LLIN = long-lasting insecticidal net; MoHSW = Ministry of Health and Social Welfare; M&E = Monitoring and Evaluation; RHMT = Regional Health Management Team; DMFP = District Malaria Focal Person; WEO = Ward Executive Officer; VEO/MEO = Village/Street Executive Officer; CHMT = Council Health Management Team.

Figure 2

Map of the United Republic of Tanzania. Zones (consisting each of three coloured administrative regions) are numbered according to their implementation order. 1: Southern, 2: Southern Highlands, 3: Central, 4: West Lake, 5: Lake, 6: Coastal, 7: Northern. Shaded areas represent districts within regions in which household evaluation surveys were conducted. A: Southern zone (Nachingwea and Mtwara Urban Districts; B: Lake zone (Sengerema, Rorya and Chato Districts); C: Coastal zone (Kisarawe and Rufij Districts).

Figure 3

Universal Coverage Campaign implementation timetable, mainland Tanzania. The Universal Coverage Campaign was implemented on a rolling basis from one zone to another. Light grey indicates the household registration dates and dark grey the LLIN issuing dates in the corresponding zones.

Figure 4

Equity ratio of insecticide-treated net (ITN) household ownership and use in children under the age of five years, over time (2005–2011), mainland Tanzania. ITN household ownership (dashed lines) and ITN use in children under the age of five years (solid lines) are shown for Tanzania mainland (triangles), Southern zone (diamonds) and Lake zone (squares) for the years 2005 to 2011. Coastal zone is not shown because there is only one data point (2011) available. Nationally representative data comes from national household surveys conducted by the monitoring and evaluation contractor. See main text for definition of equity ratios.

Figure 5

Number of insecticide-treated nets (ITNs) distributed, per delivery channel and ITN use in children under the age of five years over time (2004–2012). Number of ITNs distributed (bars) via the Tanzania National Voucher Scheme (light grey), Under-five Catch-up Campaign (medium grey) and Universal Coverage Campaign (dark grey) for the years 2004 to 2012. ITN use in children under the age of five years (lines and diamonds) is depicted for Southern zone (dashed line) and Lake zone (dotted line) as well as Tanzania mainland overall (solid line), including Demographic Health Survey (DHS) and Tanzania HIV and Malaria Indicator Survey (THMIS) data (diamonds). In order to retain readability of the figure, the available data points for Coastal zone (2010 and 2011) are not shown.