Ntcheu District, Malawi

12 months Post Distribution Survey Report

For

Against Malaria Foundation

From: Thomas Makwinja, Concern Universal, Malawi

Chronology and Executive Summary

- Jan-Apr 2012: Distribution of 270,00 LLINs (Ntcheu District population: 550,000)

(Majority distributed in Jan and Feb)

- Jun 2012: Post distribution survey at 6 months

(AMF summary added)

 7,646 randomly selected households were visited and 15,735 nets surveyed (6% of
the nets distributed) across the 37 health centre catchment areas.
 90% of the nets were found to be hung and in use. For 10 of the areas the average
was 84% (range 78-88%) and for 27 of the areas the average was 95% (range 91-
98%).
 This is a high hang-up level.
 99% of the nets were found to be in 'very good' condition (fewer than 2 holes of up
to 2cms in size).
 The condition of the nets when compared with our expectations is: excellent

This report:

- Apr/May 2013: Post distribution survey at 12 months

(AMF summary added)

 9,250 randomly selected households were visited and 18,580 nets surveyed (7% of
the nets distributed) across the 37 health centre catchment areas.
 85% of the nets were found to be hung and in use. For 21 of the areas the average
was 91% (range 84-95%) and for 16 of the areas the average was 78% (range 71-
82%).
 This is a high average hang-up level after 12 months, albeit 16 of 37 areas have the
potential for higher levels of hang up.
 89% of the nets were found to be in 'very good' condition (fewer than 2 holes of up
to 2cms in size).
 The condition of the nets when compared with our expectations is: excellent
 POST DISTRIBUTION SURVEY-12 MONTH SUMMARY DOCUMENT

INTRODUCTION

The Malawi government through the directorate of preventive health services in the
ministry of health established the National Malaria Control Programme (NMCP) with the
goal of reducing the level of malaria related morbidity and mortality from 2004 figures by
50% by 2010 and 75% by 2015. To achieve these goals the NMCP laid down malaria
preventive and control interventions which included health promotion, distribution and
usage of Long Lasting Insecticide treated Nets (LLIN), intermittent presumptive
treatment for malaria in pregnancy and indoor residual spray as primary malaria
preventive interventions.

The government of Malawi with assistance from the Global Fund and other partners
was in 2011to 2012 implementing a universal coverage national campaign with long
lasting insecticide nets. Various donors were contributing LLINs for the national
campaign like: Global Fund to fight Aids, Tuberculosis and Malaria offered 4,740,480
LLIN, USAID’s President’s Malaria Initiative, 477,000 LLINs; Against Malaria Foundation
contributed 268,000 LLINs and Millennium Village Project 30,000 LLIN nets.

It is against this background that Concern Universal Malawi and Ntcheu District Council
conducted a Universal Long Lasting Insecticide Net (LLIN) Distribution Programme
across Ntcheu District as part of the National Malaria Control Programme Universal
distribution campaign. Against Malaria Foundation provided the 268,000 LLINs for
distribution in Ntcheu District whilst funds for distribution operations were provided by
Irish Aid. This stock of nets was sufficient to ensure coverage of every sleeping space in
Ntcheu District.

An eighteen months post-distribution survey was conducted from April to May 2013 to
examine household Long Lasting Insecticide treated Nets (LLINs) correct usage, hung
up percentage of LLINs and condition of LLINs in 250 households at each Health
centre. Ntcheu district has 37 health facilities.

HOW THE WORK WAS PLANNED

The PDS took place from fourth week of Apri to second week of May 2013 for the data
collection from all the thirty seven health facilities and data entry started soon after the
data collection started two days after data collection. The survey reached 250
households randomly selected from each health centre.

The first three days was orientation of the survey form for the sixteen data collectors.
During the orientation procedure for identifying the household was discussed based
(random sampling) on the house hold listing that was available. The orientation included
the pretesting of the survey form.

The training was done by concern universal staff main areas covered during the
orientation were: Logic of the survey form (net condition, type of the net, and who
provided the nets like AMF nets, number of sleeping spaces and hung nets against the
received nets), random sampling, interview guide and lastly pretesting of the survey
form.

WHAT MECHANISM WAS USED TO RANDOMLY SELECT THE HOUSEHOLDS?

Ntcheu district has 37 Health facilities. The standard sample size for each health facility
was 250 respondents in each health facility (catchment Area). The health facility
catchment area was taken as one area. Therefore Ntcheu district had a total of 9250
samples.

Ten villages in each catchment area were selected using Probability Proportional to size
sampling (PPS) method. The process involved reviewing data from both Ministry of
Health list of villages under each catchment area, calculating the cumulative population
for each catchment area, calculating the sampling interval by dividing total cumulative
population by 10 and choosing the random number using the Random Number Table to
determine the first village to be interviewed. This generated a list of 10 villages to be
interviewed. The number ten was chosen due to the budget and time. With this process
villages with larger population had higher chances of being selected. The process of
village selection was done prior to the data collection during the training so that the
EHOs should understand and appreciate the process of random sampling.

In the village households for interview were randomly selected using the household list
from Net distribution register. Using a random number table the reference household
was selected from this reference household the nearest household was taken using the
nearest household 25 households were reached in each area. The household
interviewed was supposed to have received the LLINs during the 2011/2012 AMF nets
distribution as eligibility for being interviewed. If the household did not receive the AMF
nets the next nearest household was taken until the number of twenty five was reached.
If it happens that villages close by were selected the household interviewed were
marked PDS showing that interview has already taken place. In the household heads
men or women were interviewed upon given consent and form was signed to indicate
acceptance.

Criteria for Selecting Data Collectors & Supervisors

The selection of Data Collectors was based on those that were coming within the district
health office mainly Environmental Health Officers (EHOs) who are the supervisors for
the Health Surveillance Assistants and are aware of the catchment areas and those that
will be availability for the entire exercise period and committed to random sampling.

How the work was done

There were 16 EHOs that were divided into two teams each team was visiting one
health facility per day guided by one team leader who was responsible to check that
data collection was done as planned (random selection) and the selected villages was
visited. The two team leaders were the district Malaria Coordinator and his deputy. Each
team was allocated with one vehicle. The team leader makes sure that each data
collector has taken and submitted the survey forms that were well filled. The data
collection was done in twelve days. There was one health surveillance assistant from
each health facility to lead the teams to the selected villages and was also responsible
for booking the communities on the visiting team from the district but the subject matter
was not given to the communities. This was deliberate done not to alert the
communities so that the real situation was found on the ground..

There was one concern universal staff that was responsible making sure that all the
survey forms have been photocopied, daily transport arrangements (fuelling) and that all
daily filled survey forms are reaching the data entry team and other logistics. At times
this person was going around checking the villages and households visited.

Data entry

There were two data entry personnel who had knowledge in basic computer use. Data
entry started soon after data collection (two days after data collection). The team was
responsible for data entry and latter editing. It was planned that data entry first and
editing latter but it was then changed to data editing after each facility was finished. The
data entry and editing took over one and half months which was initially planned for
fifteen days.

There was one staff from concern universal who was responsible for the data checking
during data entry this was done by taking a sample of questionnaire and see if they
were entered correctly where the data was not correctly entered the responsible data
entry staff was notified. This person was able to detect simple errors made by data
entry team members.

THE COST OF CONDUCTING THE SURVEY

In the first place we thought of using the Health Surveillance Assistants but the process
looks long and had higher costs. This process would mean going to health facilities for
two to three times (orientation to each facility, data collection supervision and collection
filled survey forms).
The survey expenses were in excess of 2.8 million Malawi kwacha refers to the detailed
budget below:

BUDGET FOR THE POST DISTRIBUTION SURVEY

No ITEM QTY UNIT COST # OF DAYS TOTAL

1 DATA COLLECTORS 16 6500 15 1560000
2 TEAM SUPERVISORS 2 6500 15 195000
3 DATA ENTRY CLERCKS 2 6500 15 195000
4 HEALTH FACILITY HSAs 1 1500 37 55500
5 REFRESHMENTS 20 400 1 8000
6 PENCILS 20 50 1 1000
7 SHAPERNERS 20 100 1 2000
8 TONER 1 40000 1 40000
9 PENS 20 60 1 1200
10 INK PADS 20 300 1 6000
11 REAMS OF PAPER 10 2350 1 23500
12 FUEL 80 714.9 12 686304
13 INK/INK PADS 20 600 2 24000
14 FILE FOLDERS (PLASTIC) 20 200 1 4000
TOTAL Mk 2,801,504

WHAT WENT WELL?

 All the selected villages were visited.

 Survey was easily understood by the data collectors less mistakes.

 The survey form was short only one page of two forms which was ideal for the
interviewees and interviewers hence we did not use a lot of papers.

 250 households were visited per each health facility.

 Communities/household heads were allowing the data collection teams to enter

into their households to see hung nets and condition.

 Transport was available throughout the exercise.

 Management support and commitment towards the activity concern universal and
MOH as staff were not called for other activities.
  The data collectors were available throughout the whole exercise.

WHAT DID NOT GO WELL?

 In some villages (six) there were funerals so the teams had to cancel and re-plan
the visits.

 Internet problem let us to take long time to finish data entry as well (frustrating
situation).

 Changing of the survey form when the data collection was in progress.

 The data entry team demanded for extra money as they spent more days than
planned.

 There was no budget line for the activity hence we lost time during the process of
identifying where to take the resources.

LESSONS LEARNED

 There is need to create the budgets for this activity during the next surveys form.

 The data entry team has to be allowed to do it where internet is working well.

 EHOs who were involved during the process of net distribution were able to catch
the process fast than those who were not part of the distribution exercise.

 The data entry team need to be paid per health facility entered and edited.

 Random sampling gave a chance to villages that were in remote areas to be

visited of would not have been visited if random sampling was not done.

 Communities were not told of the survey hence real situation was found on the
ground as compared if they would have been told of the survey.

ANY FURTHER COMMENTS

 There is need to integrate this process into the Environmental Health Officers
monitoring system so that the district should be able to monitor and use the data
in future.

 Depending on the situation of the district this training should be thought of during
the net distribution orientation to Health Surveillance Assistants and be
incorporated in the monitoring forms of Health Surveillance Assistants so that it
should cut costs.