INTRODUCTIONIn 2013, the Zanzibar Malaria Elimination Program (ZAMEP), with support from the Johns Hopkins Center for Communication Programs (CCP), designed a continuous insecticide treated net (ITN) distribution strategy to maintain high levels of ITN ownership and use. From June 2014, when the system was rolled out, to December 2015, ZAMEP distributed 216,310 ITNs through continuous distribution (CD) (Table 1).

Table 1. ITNs distributed through CD channels June 2014– December 2015, by district

Through the CD system, ITNs are given to pregnant women and caretakers of young children through free distribution at 1st antenatal clinic (ANC) visit and through the Expanded Program on Immunizations (EPI) during 9 month measles vaccination. At the community level, eligible households request a coupon from the sheha (local government leader), and then exchange the coupon at the nearest health facility for a new ITN. Coupons are then returned to ZAMEP. In addition, district malaria surveillance o�cers can issue coupons to household members identi�ed through active case detection, if there is a shortage of ITNs.

The evaluation revealed positive perceptions of the CD program across levels and locations. The CD system was viewed by participants as part of successful malaria control e�orts on Zanzibar, contributing to the reduction in malaria cases. The system was further perceived as having a positive impact on ANC and EPI attendance, community knowledge, and ITN use.

The CD system was observed to be functioning overall, with variation in performance observed across locations. Among high performing locations, there was e�ective coordination across levels, timely and accurate reporting, strong buy-in from shehia and health facility participants, and e�ective communication and community engagement e�orts. In these locations, stakeholders often identi�ed opportunities to improve the system. Examples of positive innovations included use of health committees, which brought together community members, shehas, and health facility sta�, and engagement of academic and religious leaders in sensitization campaigns.

Among lower performing locations, challenges included limited stockouts of ITNs and/or coupons and inadequate storage facilities for ITNs, due to insu�cient space, lack of security, and in one instance, rodent infestation. Additional challenges reported by participants included delays in reporting, a lack of communication between the shehia and health facility levels, and time constraints associated with following up with community members to ensure coupons were redeemed.

Overall, participants were highly satis�ed with the training ZAMEP provided on the CD system, but felt that additional training and supervision would be bene�cial, particularly at the shehia level. While the CD program and associated communication channels were viewed as reaching a large majority of the population, participants noted challenges in serving migrant and hard to reach populations. More challenges were noted in remote rural areas, particularly on Pemba Island, and within the community-based distribution system at the shehia level.

CONCLUSIONSOverall, the CD system in Zanzibar is functioning well across channels, with some locations functioning at a high level. It will be important to address the speci�c needs of lower-performing areas and to draw on lessons learned and innovations from high-performing areas to improve consistency and performance across Zanzibar. Speci�c opportunities include: establishing an improved feedback mechanism between the shehia-level and health facility–level sta� to improve communication and promote timely reporting; guaranteeing adequate training, and su�cient refresher trainings for sta�, particularly at the shehia level; outreach for hard-to reach populations and migrants; and expansion of forums to discuss challenges and showcase positive innovations across levels and locations.

April Monroe1, Mwinyi Khamis2, Waziri Nyoni3, Kanuth Dimoso3, Abdullah S. Ali2, George Greer4, Naomi Kaspar4, Joshua Yukich5, Hannah Koenker1

1VectorWorks Project, Johns Hopkins University Center for Communication Programs, Baltimore, MD, United States, 2Zanzibar Malaria Elimination Programme, Zanzibar, Tanzania, 3Johns Hopkins Center for Communication Programs, Dar es Salaam, Tanzania, 4 US President’s Malaria Initiative, Dar es Salaam, Tanzania, 5Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, United States

Presentation number 1658

PROCESS EVALUATION OF CONTINUOUS INSECTICIDE TREATED NET DISTRIBUTION IN ZANZIBAR

District ANC EPI Community Total

Urban 5,996 3,884 15,062 24,942

South 1,428 1,690 7,741 10,859

North A 5,703 4,512 15,718 25,933

West 8,655 9,595 17,466 35,716

Central 2,498 2,765 13,951 19,214

North B 1,822 2,050 10,722 14,594

Mkoani 3,853 3,838 10,226 17,917

Chake Chake 4,187 3,827 13,348 21,362

Micheweni 4,588 4,021 13,878 22,487

Wete 4,318 4,089 14,879 23,286

Total 43,048 40,271 132,991 216,310

National District Shehia Health facility Total

Unguja 3 2 8 9 22

Pemba 0 3 8 6 17

Total 3 5 16 15 39

METHODSCCP and Tulane University, through the VectorWorks project, carried out a process evaluation of ZAMEP’s CD system in April 2016.

Speci�c objectives included:1. Identify to what extent the CD strategy is being implemented as designed.2. Identify what challenges stakeholders, at each implementation level, face in delivering ITNs to target groups.3. Identify potential modi�cations to improve the CD of ITNs on Zanzibar for optimal implementation.

The evaluation comprised in-depth interviews (IDIs) across each level of the CD system, including stakeholders on Unguja and Pemba Islands at the shehia, health facility, district, and national levels. Data collection also included a brief observation of ITN distribution at the health facility level and ITN storage facilities at the health facility and national levels.

RESULTSA total of 39 IDIs took place across a random sample of 8 shehias (smallest administrative unit). Interviews took place at distribution points for coupons and for ITNs, with central level stakeholders, and with health facility sta� and shehas at community level. Observations of ITN storage facilities were completed at all eight health facilities visited, along with the national-level storage facility. Of the eight health facilities observed, seven had ITNs in stock at the time of the visit. At the one health facility that did not have ITNs in stock, there were pregnant women and children present at the facility who were eligible to receive a net.

Table 2. In-depth interviews conducted

Source: Data provided by ZAMEP

This poster is made possible by the generous support of the American people through the United States Agency for International Development (USAID) and the President’s Malaria Initiative (PMI) under the terms of USAID/JHU Cooperative Agreement No AID-OAA-A-14-00057. The contents do not necessarily re�ect the views of PMI or the United States Government.

Contact: April Monroe, amonro10@jhu.edu

A health facility nurse provides an ITN to a child following measles vaccination, Unguja Island.

Health Facility, Unguja Island

A sheha reviews his ITN coupon book, Pemba Island.