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Keywords:

  • antenatal clinics;
  • cost;
  • coverage;
  • delivery;
  • insecticide-treated nets;
  • Kenya;
  • malaria;
  • pregnancy

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Kenya's National Malaria Strategy states that insecticide-treated nets (ITNs) would be considered as a free service to pregnant women assuming sufficient financial commitment from donors. In 2001, United Nation's Children's Fund (UNICEF) and the Government of Kenya brokered support to procure and distribute nets and K-O TABs (deltamethrin) to 70 000 pregnant women in 35 districts throughout Kenya around Africa Malaria Day. This intervention represented the single largest operational distribution of ITN services in Kenya to date, and this study evaluates its success, limitations and costs. The tracking process from the central level through to antenatal clinic (ANC) facilities suggests that of the 70 000 nets procured, 37 206 nets (53%) had been distributed to pregnant women throughout the country within 12 weeks. One-fifth of the nets procured (14 117) had gone out to individuals other than pregnant women, most of these at the request of the district teams, with only 2870 nets estimated to have gone astray at the ANC facilities. At 12 weeks, the remaining 18 677 nets were still in storage awaiting distribution, with more than two-thirds having reached the district, and nearly half already being held at ANC facilities. The cost of getting a net and K-O TAB to an ANC facility ready for distribution to a pregnant woman was US$ 3.81. Accounting for the 14 117 nets that had gone to other users, the cost for an ITN received by a pregnant woman was US$ 5.26. Delivering ITNs free to pregnant women through ANCs uses an existing system (with positive spin-offs of low delivery cost and simple logistics), is equitable (as it not only targets those who can afford it) and can have the added benefits of strengthening ANC service, delivery and use.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

There is no doubt that insecticide-treated bednets (ITNs) represent one of the most significant public health tools for Africa's enormous burden of malaria. Protecting young children with nets treated with synthetic pyrethroids have been shown in several studies to improve child survival (Lengeler 1998; Armstrong-Schellenberg et al. 2001). Their use during pregnancy has also been shown in community studies to improve morbid events in the pregnant woman and birth outcomes in malaria endemic areas (Dolan et al. 1993; D'Alessandro et al. 1996; Ter Kuile et al. 1999). The two trials which did not demonstrate a significant impact of ITNs in pregnancy were limited either by focusing only on hospital deliveries (Shulman et al. 1998) or by having a low coverage (Browne et al. 2001), which may have diluted any protective effects (Guyatt 2001). Encouraging the use of ITNs by pregnant women has the added benefits of protecting not only the mother during her pregnancy, but also the newborn within its first year of life (the age at which most children in endemic areas are at highest risk from malaria).

Although the health benefits of ITNs have been conclusively demonstrated under experimental conditions, the most appropriate approaches for their delivery in an operational setting remain uncertain. Protagonists of ITNs are divided over the most effective means of providing ITN services (Lengeler et al. 1996; Lines 1996; Fraser-Hurt & Lyimo 1998; Hanson et al. 2000; Lines & Addington 2001). Approaches include full cost recovery, promotion of private sector delivery (`manufacturers models'), free distribution or subsidized, cost-recovery approaches including social marketing. Differences of opinion on the appropriateness of these approaches focus on issues relating to sustainability, coverage and costs. Nevertheless, attempts to fully evaluate the coverage and cost of effective delivery of nets are notable by their absence.

In Kenya, as in many parts of Africa, access to bednets and insecticides for their treatment continues to be minimal. Poor coverage in Kenya has been noted in studies across the country (Bloland et al. 1999; Kinnear 2000; Kaburu 2001; PCA 2001). The almost universal conclusion is that knowledge of nets as a barrier to mosquitoes is not a limitation, but rather people do not protect themselves with nets because they cannot afford them.

During 1999, Kenya's Division of Malaria Control (DOMC)1 of the Ministry of Health (MoH) undertook a broad stakeholder consultation to develop a national strategy for the provision of ITNs (DOMC 2000). This strategy recommended that nets should be provided free of charge to biologically vulnerable groups, such as pregnant women and their newborn children. It was recognized that the major limitation to this approach was economic, and that the Government of Kenya (GoK) could not provide sufficient financial resources to protect all those at-risk without significant donor support. It was acknowledged that failing a donor commitment, an enabling environment for the growth in access to private-sector nets would be needed, and that socially marketed ITN products and non-governmental organizations (NGOs) have an important role in making these commodities available to communities during initial phases of the programme as a means of `pump-priming'.

The National Malaria Strategy (NMS) was launched by the MoH in April 2001(DOMC 2001) during the same month as African Malaria Day (AMD) and the second summit on malaria of African Heads of State in Abuja, Nigeria. A meeting of the National Malaria Co-ordinating Control Committee (NMCC)2 in February 2001 discussed both AMD and the NMS in the light of an urgent need to begin ITN delivery. In response, UNICEF pledged to support a time-limited campaign of ITN distribution to pregnant women free of charge. Targeting pregnant women was viewed as a viable approach and consistent with NMS recommendations. Such an approach received mixed responses from various stakeholders, raising concerns about undervaluing this commodity, sustainability and `leakage'. As a consequence it was decided that this donation by UNICEF would be tracked to provide information for the future policy of ITNs in Kenya.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Process

Following the initial agreement at the NMCC meeting held in Mombasa in February, 12 meetings were convened to consider approaches for the effective delivery of ITNs to pregnant women as part of a wider agenda in preparation for AMD. The meetings were attended by a broad stakeholder group, averaging 12 people from within and outside the MoH. Funds were sourced and managed by the UNICEF Country Office in collaboration with the DOMC and UNICEF, New York. US$ 350 000 was secured in support of the intervention allowing sufficient funds to procure 70 000 bednets and 70 000 K-O TABs (25% m/m Deltamethrin, AgroEvo East Africa Limited, Nairobi) for pregnant women. An additional 15 000 nets and K-O TAB sachets were made available from existing UNICEF stocks in Kenya to be supplied to hospital beds. The World Health Organization (WHO) made an additional contribution of 15 000 nets in April for early distribution to support AMD.

Thirty-five districts across the country were selected by the DOMC as priority target districts. Each district was allocated 2000 nets and K-O TABs for ANC attenders and between 375 and 500 for hospital beds. On 28 March 2001, a circular from the Director of Medical Services (DMS) was forwarded to all District Medical Officers (DMOs) preparing them for the arrival of the nets and insecticides and that these should be provided free of charge to pregnant women by the end of May 2001. The circular stated: `2000 [nets]… for free distribution to pregnant mothers through all antenatal clinic outlets including NGO and mission clinics in your district … Please ensure that these items reach the intended users in the shortest time possible once you receive them in the districts'. Apart from some minimal national media coverage around AMD, the letter from the DMS represented the only investment in raising the awareness of service providers and the communities.

Procurement of supplies in UNICEF is centralized through the Supply Division at Copenhagen, with items for sub-Saharan Africa being purchased through the office at Pretoria (South Africa). A request was sent to Pretoria to procure 70 000 nets and K-O TABs on 12 March. As a result of the time restrictions in availing nets in concert with AMD, Pretoria procured nets from A–Z textiles close to the Kenyan border at Arusha (Tanzania). The nets ordered were rectangular large family size (W190 × L180 × H150 cm) of white knitted 100% polyester (75 denier). The nets were packaged in bales of 125 and dispatched from the factory on 19 April. They were shipped by road, cleared at the Kenyan border and arrived in Nairobi the same day. A purchase order was placed by the UNICEF representative in Pretoria for 70 000 K-O TABs from Aventis in South Africa on 23 March. These were packaged in boxes of 100s and air-freighted from Johannesburg to Nairobi on 7 April. The clearing agent for the nets and K-O TABs was Mechanized Cargo Ltd, where supplies were stored until collected by DELIVER3 for distribution to the district headquarters. Net distribution to the districts was initiated on 10 April, and the last delivery was made on 17 May.

Survey design

Five types of forms were used for data collection at the district level:

•District Health Management Team form (DIST1) to collect information on the management of nets at the district level.

•Antenatal form (ANTE) to collect data from exit interviews with pregnant women attending ANCs.

•First facility management survey (FAC1) to collect information on the management of nets at the ANC.

•Second facility management survey (FAC2) to collect information on net allocation and costs incurred at the ANC.

•Resource consumption form (DIST2) to collect information from the district level on costs incurred.

In mid-May 2001, telephone interviews were initiated with the DMOs or District Public Health Officers (DPHOs) in each of the 35 targeted districts to establish the receipt of nets and K-O TABs and their policy for distribution and net treatment using the DIST1 form. Follow-up interviews were held in mid-July to determine the exact quantities of nets that were still in storage, had been distributed to ANCs or had been distributed to other community members.

Four districts selected as part of the DOMC's Roll Back Malaria monitoring and evaluation were used to obtain detailed data on the process of net distribution at the ANC facilities. These districts were Bondo, Kwale, Makueni and Gucha, each representing one of the four major malaria ecologies of Kenya. From the telephone interviews held with the DMOs or DPHOs in mid-May 2001, a list was drawn up of the facilities that were to receive nets in each district. This was expressed on a GIS platform using existing geo-referenced information on the position of health care facilities, and ANC facilities were randomly sampled within a grid system in each district with the purposive sampling of the district hospital. The aim was to cover a minimum of 10 facilities or at least those receiving 50% of the nets.

In each of the four selected districts, exit interviews were undertaken with all mothers attending these ANC service outlets on specified days using the ANTE form. Questionnaires were designed to capture basic information on whether nets were issued, pre-treated, and the information given to the ANC attendee. Questionnaires were translated into KiGusi, KiLuo, KiKamba and KiSwahili. The exit interviews were initiated at the end of May in Kwale, Gucha and Bondo, and in mid-June in Makueni. The timing of the interviews reflected differences in the districts' time frame for net distribution. In each district, exit interviews were completed within a 2-week period.

Immediately following the exit interviews, facilities were audited using a separate questionnaire (FAC1) to identify the dates that nets and insecticides arrived at each facility, the recording systems used to monitor distribution, whether nets were treated by facility staff, and the balance of nets left in stock. The second facility interview (FAC2) was undertaken in mid-July to follow-up on the net distribution that had occurred since the exit interviews to establish the allocation of nets to pregnant women, and the cost incurred in transporting nets from the district to the facility. The timing of the surveys is indicated in Fig. 1.

image

Figure 1.  Time profile for the net distribution and evaluation surveys in the four selected districts (Bondo, Gucha, Kwale and Makueni).

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Further telephone interviews were held with the District Health Management Teams (DHMTs) in the four selected districts to establish the distribution process and any costs incurred (using the DIST2 form). At the central level, interviews were held with the key stakeholders and implementing partners (UNICEF, DOMC, KEMSA4 and DELIVER) to establish the delivery success of nets from the central level to the districts, and the costs of procurement and delivery.

Data analysis

Monitoring of the distribution success at each level (from Nairobi through to the district ANCs) established the number of nets that had reached ANC facilities by July 2001, those still held in storage and those that had been allocated to other users at the district level. Net allocation to non-pregnant women and other users (`leakage') at the ANC facilities in the four selected districts was determined using a variety of methods depending on the availability of data at the facilities. In Makueni and Kwale, daily bednet and ANC attendance registers were compared alongside balances of nets at the facility. For Gucha and Bondo combinations of exit and facility interviews were used with registers where these were available.

The cost analysis considered only the financial costs incurred to all implementers, including UNICEF (for net and K-O TAB procurement and delivery to Nairobi), DELIVER (for delivery to the districts) and the district health teams (for delivery to the ANC facilities). The opportunity costs of using existing resources, such as personnel and vehicles, were not assessed. The costs were expressed as the financial cost per ITN delivered to an ANC facility. Incorporating the estimate of `leakage' to other users (both at the district headquarters and the ANC facilities), the financial cost per ITN to a pregnant woman in the target districts between April and July 2001 was assessed.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Delivery to the districts

Through interviews with DOMC, KEMSA and DELIVER at the central level and the DMOs and DPHOs at the districts, it was established that by mid-July, 92% (64 175) of the 70 000 nets procured had reached the target district headquarters. One district (Turkana) received no nets (as DELIVER had no planned visit to this area) and one district (Vihiga) only received 300 nets as the DMO stated that he would collect his consignment but underestimated the bulk. These 3700 (5% of the total) were still in Nairobi after 12 weeks. The other 2125 nets (3% of the total) were at Garissa depot awaiting collection by Wajir and Mandera. DELIVER do not drive directly to these districts because of security problems, and only 1875 nets had been collected by mid-July. A total of 10 925 (17%) nets delivered to the district headquarters (five districts receiving 2000 nets, Vihiga and Mandera) had no accompanying K-O TAB supplies.

Delivery to the ANCs

Twenty of the 34 districts (59%) that had received nets provided detailed information on their distribution to the ANCs (see Appendix and Figure 2). The 300 nets taken by Vihiga DMO were assumed to still be in storage and 13 districts receiving 2000 nets and K-O TABs were assumed to have the same net distribution as the eight districts receiving 2000 nets and K-O TABs that did provide detailed information. Overall, it was estimated that 49 531 nets (77% of the 64 175 received at district headquarters) went out to ANC facilities by mid-July. A total of 4756 were still to be distributed and 9888 went to other users. Of the 49 531 nets estimated to have gone out to ANC facilities, 15% (7186) went out without insecticide. Of the 35 districts targeted by the programme, it is estimated that 30 had distributed some nets to ANC facilities by mid-July.

Table 1. Appendix The distribution success from Nairobi to the antenatal clinic (ANC) facilities Thumbnail image of
Table 2. Appendix (continued) Thumbnail image of
image

Figure 2.  A map of Kenya indicating the districts that were targeted for nets and completed telephone and field interviews.

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Process at the district level

Interviews with the DMO and the DPHO in Bondo, Kwale, Makueni and Gucha established that overall these districts followed the instructions laid out in the circular sent by the DMS. The districts assigned between 1850 and 2250 of their entire net allocations to ANC facilities (see Table 1), and almost every GoK facility offering ANC services received a net allocation. In Gucha district, nets and K-O TABs were also allocated to four facilities that did not offer ANC services as the DHMT decided to target young children as well as pregnant women. The other three districts targeted only pregnant women. Gucha and Makueni districts provided allocations to some Mission, NGO and private facilities, whereas Bondo and Kwale only targeted GoK facilities. ANC facilities collected or received their net and K-O TAB allocations between 4 and 10 weeks of the commodities arriving in the district (see Figure 1). Gucha district delivered all supplies to the facilities within 4 weeks whilst there remained a balance of supplies in Makueni district by mid-July (approximately 100 nets). None of the four districts surveyed requested any system of cost-retrieval against the nets issued.

Table 1.   Summary data on the distribution process in the four selected districts Thumbnail image of

No detailed instructions were given to district teams on how to allocate and distribute the nets amongst the facilities, and as a result there was marked variation in this process. Gucha and Bondo districts decided to allocate fixed numbers of nets according to facility type (hospital, health centre or dispensary), Kwale did it exactly proportional to the annual ANC attendance, and Makueni used a combination of both approaches. Bondo and Makueni districts advised facilities to distribute nets with K-O TABs and instructions on dipping, whereas Gucha and Kwale districts recommended that the facilities pre-treated the nets. Gucha and Makueni districts used an existing seminar at the district headquarters to also train nurses on the ITN programme, the importance of bednets and how to treat them with insecticide. Kwale sent out a circular to all facilities receiving nets (personnel were already trained on net dipping), and Bondo informed each facility verbally on receipt of their nets. Gucha and Makueni districts distributed most nets to the nurses attending the seminars and they carried them back using public transport, whereas Bondo and Kwale used GoK vehicles to distribute the nets.

Process at ANC facilities

A total of 51 ANC facilities were surveyed in the four districts. These represented 36% of the facilities receiving nets, and 65% of the total net distribution (Table 1). Despite district-level instructions on pre-treating vs. issuing nets with K-O TABs to mothers, facilities decided themselves precisely how the intervention should be delivered. For example, in Makueni district 62% of facilities gave out nets to ANC attendees pre-treated, and in Gucha district, 23% of facilities were issuing untreated nets with K-O TABs. Both Bondo and Kwale districts adhered to the district instructions.

Once at the facility, nets were distributed quickly in Gucha and Kwale districts. At nine facilities in Gucha district all nets were distributed within 2 days. In Makueni, one facility only issued nets to women from `malaria-risk areas', and at another, nets were only issued when the Matron was present. In Kwale district, mothers were often asked to return for their nets on the following day as only a limited number of nets were treated each day. Two facilities in Kwale had to stop distribution for a few weeks because there was no water to dip the nets.

A total of 1445 pregnant women leaving ANC facilities were interviewed in the four districts (Table 1). Knowledge by pregnant women of the ITN service was low in Makueni and Bondo districts, and higher in Kwale and Gucha districts. Overall a third of all attendees knew that the ITN service was being offered. Of those interviewed, only half were attending the clinic when nets were available for distribution, the rest had come to the facility either before net distribution had started or by the time it had finished (as there were only a limited number of nets). Of those women attending the ANC facility when nets were available for distribution, a fifth did not receive a net. The reasons for this varied with each facility but included selectively administering nets only to women from areas at high risk to limitations on net quantities imposed by only treating 10 nets per day. For women provided with a K-O TAB, 87% were told how to treat the net at home, but only half were told about re-treatment.

Delivery at the ANCs

As indicated from interviews with DHMT staff the majority of nets in Kwale, Makueni and Bondo were targeted for pregnant women at facilities offering ANC services. In these three districts, leakage (represented as anomalies between records on registers, balances in the stores and net distribution during exit interviews) was estimated to be 6% (Table 1). Overall, 77% of nets delivered to ANCs (4382 of 5734) in these three districts were estimated to have gone to pregnant women by mid-July.

Observations at facilities in Gucha District conformed to a district decision to provide nets to young children. Of the 2000 nets received at the ANC facilities in Gucha, 640 (32%) went to pregnant women, 1359 went to young children (68%) and one remained in storage (see Table 1).

Telephone interviews with the other districts receiving nets had established that those being sent to ANC facilities were to be targeted for pregnant women only. Assuming facilities in the other 26 districts that had sent nets to ANCs allocated them according to that observed in Bondo, Kwale and Makueni (i.e. 77% went to pregnant women, 17% were still to be distributed and 6% were `leaked' to other users), it is estimated that 32 184 nets had reached pregnant women in these districts by mid-July.

For all 30 districts, a total of 37 206 nets are estimated to have reached pregnant women. This is equivalent to 53% of the total nets procured (70 000), 73% of those going to somebody (51 323) and 75% of those reaching ANC facilities (49 531). From the nets that reached the ANC facilities by mid-July, a total of 8096 were still waiting to be distributed, 1359 had gone to young children in Gucha and 2870 represented `unofficial leakage'. As four of the districts that had not received K-O TABs were distributing nets to ANC facilities, as many as 5533 nets given to pregnant women (77% of 7186) may have gone out untreated.

Overall success of the distribution

Of the 70 000 nets brought into Kenya by UNICEF in April 2001, 37 206 (53%) are estimated to have reached pregnant women in the targeted districts within 12 weeks. More than a quarter of nets procured (18 677) remained to be distributed, but most of these had reached the target districts by mid-July. The other 14 117 nets were estimated to have gone to somebody other than a pregnant woman. Most of this `leakage' to other community members (80%) occurred under the direction of the DHMTs, with only 2870 (4% of the total nets procured) having gone astray from the ANC facilities.

Costs

The purchase prices for the commodities distributed were US$ 2.27 for a net and US$ 1.23 for a K-O TAB (Table 2). The costs for transporting and clearing these commodities to Nairobi represented a cost per unit of US$ 0.06 per net and US$ 0.0454 per K-O TAB. The financial costs incurred in distributing the nets to the districts were borne by DELIVER. The incremental costs to DELIVER for transporting the nets to the districts (fuel and per diems for staff) were estimated at US$ 0.083 per net + K-O TAB unit.

Table 2.   Itemized costing menu for insecticide-treated bednets (ITNs) delivery to pregnant women through antenatal clinics (ANC) Thumbnail image of

Records at the district indicated that the cost of using GoK vehicles to transport nets to the ANC facilities was US$ 0.27 per net in Kwale (includes fuel, lunch allowances and a minor car service) and US$ 0.10 per net in Bondo (includes fuel and lunch allowances). Interviews with the health providers at the ANC facilities established that the cost of using public transport was approximately US$ 0.08 per net in Makueni and US$ 0.04 per net in Gucha. The average estimated cost per net + K-O TAB distributed from the district to ANCs was US$ 0.12 per unit. This represents a conservative estimate as the nets to the district hospital ANC will have zero costs.

The total financial cost of delivering a bednet and K-O TAB to an ANC facility in Kenya was US$ 3.81 (Table 2). The major cost item was the CIF price of the net at 61% of the total cost, followed by the CIF cost of the insecticide at 33%. Accounting for the 14 117 nets that had gone to non-target groups, the cost for an ITN to a pregnant woman was estimated at US$ 5.26.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

The delivery of 70 000 nets and K-O TABs in April 2001 represents the single largest operational distribution of ITN services in Kenya to date. We have attempted to assess the success of this approach in reaching pregnant women, using varied sources of data, records and survey approaches. Tracking the distribution of nets throughout a country is a difficult exercise, as highlighted by the paucity of similar studies in the literature, but it is a critical component of monitoring and evaluation. The assessment went as far as establishing the number of nets received by pregnant women (contact coverage), but did not assess how the net is used within the homestead.

We estimate that of the 70 000 nets procured, 37 206 had been given free to pregnant women within 12 weeks (with at least 85% being treated with a K-O TAB). Reaching only half of the target group may at first sight seem rather disappointing, though when put into context this achievement is quite remarkable for the following reasons. First, there were marked time constraints, both in mobilizing this effort and in distributing nets to pregnant women. Distributing 37 206 nets from Nairobi to pregnant women at the periphery of the health service throughout Kenya within a period of 12 weeks represents an average net movement of over 3000 nets per week. Furthermore, it was estimated that after 12 weeks, more than two-thirds of the nets not yet distributed had reached the target districts and most of these were already at the peripheral ANC facilities. It is expected that these nets would have been distributed to pregnant women shortly after this evaluation exercise. Secondly, the distribution relied on an existing system rather than implementing a vertical delivery approach. Given the resource limitations of this over-burdened system, delays in distribution would be expected. Though mobilizing this distribution was not an easy task, most districts received nets and most districts had initiated their distribution to ANCs. Even in the absence of GoK transport, DHMTs were able to get nets from the district headquarters into the peripheral ANC facilities by encouraging health personnel to take these rather bulky items by public transport. The whole process relied very much on making the most of opportunities and existing resources, which also meant that the delivery costs were low.

The delivery cost for getting ITNs from Nairobi to ANCs at peripheral health facilities throughout the target districts was only US$ 0.20 per unit (net + K-O TAB). The total cost of providing an ITN to an ANC facility was less than US$ 4, which is comparable with some of the lowest published prices for the bulk purchase of nets alone in Africa (Binka et al. 1997; Curtis et al. 1998; Guyatt et al. 2002). As 14 117 nets were estimated to have gone to someone other than the target group (pregnant women), it is appropriate to adjust the cost per ITN to absorb this distribution of nets to other individuals. This suggests a provider cost of US$ 5.26 per net + K-O TAB delivered to a pregnant woman, which is almost five times cheaper than the estimated cost of protecting a child less than 5 years with an ITN in a low-income country (Goodman et al. 2000).

The diversion of a fifth of the nets procured to community members other than pregnant women is an issue that needs to be addressed in any future implementation. However, it is important to recognize that the net `leakage' to other users is not the same as `wastage' observed for other commodities, such as drugs, because someone ends up using the net, even if this is not a pregnant woman. In addition, most of the `leakage' represented decisions at the district level to direct these nets to other community members. It is estimated that only 2870 nets were unofficially given to non-pregnant women at the ANC facilities.

Information is an important component of any strategy. Characteristic of the free delivery of nets initiated in Kenya in April 2001 was a marked lack of information to the providers. Increased awareness at all levels in the distribution process on the importance of distributing ITNs to pregnant women would aid in reducing the number of nets going to other community members. This dissemination of information needs to extend beyond the service providers to the clients, as not all pregnant women receiving a K-O TAB were told how to treat the net, and only half were told about re-treatment of nets.

Improving information at all these levels would greatly improve the efficiency of the delivery process, but inevitably would require additional costs and effort by the varied implementation partners. If free ITN distribution to pregnant women went to scale in Kenya, the target population (excluding Nairobi) estimated in 2002 would be approximately 1.44 million. This assumes 1 525 561 pregnant women (KMIS 2001) and an ANC attendance (at least one visit) of 94.5% (CBS 1999). If this delivery was supplemented with an improved information package including an awareness raising campaign within the districts, information leaflets and a process of monitoring, this would represent an incremental cost of US$ 0.19 per ITN (Table 2). The total cost per ITN delivered would be US$ 4 [reducing to as little as US$ 3.36 if the lower price of US$ 0.59 for a K-O TAB currently paid by PSI (Jane Miller, pers. comm.) is secured]. This would represent an investment of up to US$ 5.8 million every year. It is clear that sustaining donor commitment will be critical to the future success of this approach to ITN delivery in Kenya. With this support it would be possible to saturate the entire country's at-risk population (all districts excluding Nairobi) within 7–11 years (assuming between two and three people share a net).

Many approaches to the delivery of health care commodities insist on an aspect of cost recovery to ensure sustainability. But cost recovery does not ensure sustainability, and operating such a scheme can be logistically complicated, expensive and by definition inequitable. Although sustainability will be dependent on donor support, administering nets free of charge to biologically vulnerable groups such as pregnant women is a cheap, simple and equitable approach to the delivery of ITNs.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References

Financial assistance was provided by the Wellcome Trust, UNICEF (#SSA/KENA/2001/00002112-0) and KEMRI. H.L.G. is in receipt of a Wellcome Trust Research Career Development Fellowship (055100) and R.W.S. has a Senior Research Fellowship in Basic Biomedical Science (033340). We would like to thank all those who answered our many questions at the central level (representatives of UNICEF, DELIVER and KEMSA); the DMOs, DPHOs and other members of the district public health offices; the ANC facility staff and the pregnant women attending ANCs. We would also like to thank the Research Solutions team of fieldworkers and supervisors under the direction of Jane Mugo for undertaking the exit and facility interviews. The paper is published with the permission of the director of KEMRI.

Footnotes
  1. 1A recently formed division within the Ministry of Health mandated with the operational aspects of the National Malaria Control Programme.

  2. 2A senior management committee established to provide guidance to DOMC.

  3. 3Formerly the Family Planning Logistics Management (FPLM) Unit, DELIVER is an NGO funded by USAID to manage the distribution of family planning commodities on behalf of the MoH.

  4. 4Kenyan Medical Supplies Agency, a division of the MoH involved in the procurement, storage and distribution of medical supplies.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
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