Annual Review - Summary Sheet
Title: Support to universal access to long lasting insecticide-treated nets in Equateur
Programme Value: £24m
Programme Code:
Review Date: February 2015
Start Date:07/01/2011
Summary of Programme Performance
1
2
Year
2
A+
Programme Score
Low
low
Risk Rating
3
A+
low
End Date:31/10/2015
4
A
low
Summary of progress and lessons learnt since last review
The last annual review focused on the achievements of the Equateur mass campaign to distribute Long Lasting
Insecticide Treated Nets (LLINs), which was by then complete. Since then, the programme has shifted to one of
routine distribution of nets, with the aim of maintaining coverage and therefore the positive health impact, until the
next mass distribution. This is currently scheduled for November 2015. Therefore, this annual review focuses only
on the routine distribution and accompanying activities.
The routine distribution itself suffered from several important setbacks. These include delays in procurement,
problems with staff recruitment and finally the outbreak of Ebola in the province. After the outbreak, distribution
activities were suspended for four months in 12 of the 42 targetted health zones. However, despite the slow start
and access problems, the key milestone of number of nets distributed had reached 94% of its target by December
2014. The project has successfully procured all the necessary LLINs for routine distribution and they are now
available in each health district. The three other supporting outputs relating to: Behaviour Change; Communication;
Monitoring and Evaluation; and Health Systems Strengthening, are all on track overall. To elaborate: the project has
played a key role in reinforcing and maintaining behaviour change acquired through the mass campaign and it has
strengthened the health system by providing training and supervision as well as supporting the activities by
provincial, district and health zone teams. The project has also established a good partnership with the national and
provincial government. On balance, however, we have decided to award an A score, given the importance of the nets
distributed in a context where the Ebola outbreak prevented routine activities in 29% of the targeted health zones for
four months. However, efforts must be made to improve the monitoring of the project which has not yet caught up
from its slow start.
Reflections and Lessons
 This project is contributing to more than half of the 9 million LLINs targeted by the DRC Country Operational
Plan. As DRC is recognised worldwide to be the country with the second highest burden of malaria, this project
is fully in line with DFID’s Results Framework for Malaria and has a focus on the prevention services identified
to support the achievement of mortality and morbidity reduction.

LLINs are recognised by the national malaria programme (PNLP) to be a major and a cost effective intervention
to prevent malaria in DRC and they have been implemented for more than 9 years. According to the most
recent Demographic Health Survey (DHS 2013-14) there has since then been substantial progress on ownership
and use of LLINs, including by pregnant women and children under five (U5) who are both important target
groups. Nationally, the LLIN utilization by U5 increased from 6% in 2007 to 56% in 2013 i. We would expect this
to have a substantial impact on the level of U5 mortality as malaria is recognized to be one of the three major
causes of child mortality. So this could be part of explanation for the decrease of childhood mortality: U5
mortality has decreased from 148 per 1,000 live births in 2007 to 104 in 2013 ii.

Nonetheless, there remain some questions about the LLIN approach. In Equateur, 83% of households possess
LLINs but only 63% of households used a LLIN the night before the DHS survey. This raises the question of
whether there is a problem of acceptance of LLIN by the population or access to LLINs, or both. In order to
explore this, the project is implementing operational surveys to assess the use of the nets and determine the
factors that could prevent their use.

When the routine distribution began, activities were initially implemented only in the public health facilities. It
became clear that this was not sufficient to deliver the target of nets distributed, so in October, private health
facilities (where most pregnant women seek health) were integrated into the programme. In future, this
comprehensive approach should be used from the outset.

According to the current information from PNLP, the whole province will not be covered by the next mass
distribution in 2015. One district will be supported by the DFID DRC Health care programme (ASSP) using nets
donated from AMF (Against Malaria Foundation), two districts will be supported by USAID and the two
remaining districts: Mongala and Tshuapa (with 24 health zones which represent more than the half of the
zones where we are implementing routine distribution) are still looking for funds and might not be covered in
2015. We need to work with PNLP and others to try to find a solution to this.
Gender :
This project predates the introduction of gender reviews into DFID DRC’s regular programme management
approach. It is focused on distribution of bed nets to vulnerable people, especially pregnant women and children
under five. It therefore has an inherent positive gender focus. The distribution of bed nets is one of the three
components of DFID DRC’s new malaria project: “Support to Malaria Control”. This new programme does have a
regular gender review. We propose that for the short remaining duration of the older project, we will incorporate it into
this existing regular gender review. Population Service International (PSI) – the implementing partner - is currently
developing a gender strategy and we will update the gender review in May 2015.
Annex 1: ‘Support to Malaria Control’ gender review (to be updated in May 2015) .
A. Introduction and Context (1 page)
DevTracker Link to Business Case:
http://devtracker.dfid.gov.uk/projects/GB1-202251/
DevTracker Link to Log frame:
http://devtracker.dfid.gov.uk/projects/GB1-202251/documents/
Outline of the programme
Malaria is a significant public health problem in the Democratic Republic of Congo, with 97% of the population living
in endemic zones and a malaria prevalence rate of 32%. Malaria is the leading cause of morbidity and one of the
three highest causes of mortality, especially among women and children under five, for whom malaria accounts for
54% and 48% respectively of all hospitalisations. In 2006, DRC was estimated to have 11% of all malaria cases in
the WHO African region.
The Government of DRC’s National Malaria Control Programme (Programme National de Lutte contre le Paludisme,
PNLP) has a five-year strategic plan that was developed in 2008 with support from international partners, including
DFID. This strategic plan aims to ensure 80% of the population have – and correctly use - long lasting insecticidetreated nets (LLINs). This is to be achieved by the distribution of LLINs to all households, complemented by
communication and social mobilisation activities.
The goal of this project is to contribute to the reduction by 50% of malaria-related morbidity and by 20% of malariarelated mortality in children under five in DRC. The project purpose is to maintain and increase correct LLIN use
among under five children and pregnant women in Equateur province.
The project started in December 2010. The delivery mechanism of bed nets was initially carried out through a mass
campaign for the whole province (during the two first years of the project – 2011 and 2012). A cost extension was
approved in 2013. This was for routine distribution, in order to maintain the health impact of the completed mass
distribution until the next mass distribution due in November 2015. The routine distribution of LLINs is taking place
through health zones’ structures in 42 health zones out of the 69 in Equateur province. The 27 other health zones are
already covered by DFID ASSP and other donors such as Global Fund and PMI (US President Malaria Initiative).
The project is now due to end in October 2015.
The mass distribution of 4.25 million LLINs in Equateur was expected to:

Protect 8.5 million people from malaria for up to three years

Avert an estimated 22 million episodes of malaria

Avert the deaths of an estimated 250,000 children under five

Increase demand and use of bed nets among the population of Equateur, Democratic Republic of Congo
The routine distribution of 609,616 LLINs through antenatal and growth monitoring services in health facilities in 42
Health Zones in Equateur is expected to:



Ensure that 80% of pregnant women and under-fives are protected from malaria.
Increase demand for LLINs through effective communication and social mobilisation.
strengthen the health system capacity to manage malaria prevention interventions at the operational level.
B: PERFORMANCE AND CONCLUSIONS
This annual review was conducted in January 2015 with data collected up to the end of December 2014. It covers
the implementation of the project from March 2014 to December 2014 and therefore refers only to routine
distribution activies: the preceding mass distribution was covered in previous annual reviews.
Th progress of the routine distribution has been affected by a series of delays, not all of which were within PSI’s
control. There was a 3-month delay between the end of the original LLIN mass distribution campaign project and the
approval of the new routine distribution project due to a long negotiation on the details of the extension. PSI and
DFID had to agree on the extension budget, the logframe and intervention area of routine intervention. As a result,
PSI/ASF had to close both its Mbandaka and Lisala offices and most of the project staff were transferred to other
LLIN distribution projects. After the approval, PSI/ASF had to recruit all new staff and identify new office and
warehouse space and the recruitment process took more time than expected.
The implementation started late in quarter 1 of 2014 but due to a delay in the international procurement of
commodities and the recruitment process of the staff, the distribution itself was only effective in quarter 2 of 2014.
So by this time the programme was already running 6 months late. The routine distribution started in June 2014 for
Mongala district (12 health zones ), in August 2014 for Mbandaka district (3 health zones) and September 2014 for
Equateur district (15 Health zones). With the outbreak of Ebola in the province, the 12 health zones of Tshuapa
district were placed under quarantine by the Government and no activities were implemented in those health zones
during this period until December 2014.
Annual outcome assessment
According to the logframe, the overall outcome performance is measured by three indicators which focus on the
correct use of LLINs. These indicators are:
1) the percentage of children under five who slept under a LLIN the night before the study,
2) the percentage of pregnant women who slept under a LLIN the night before the study,
3) the percentage of households that have at least one LLIN hung in the house.
For all of these indicators, the objective of the project is to see at least 80% of the targeted vulnerable groups
using effectively the insecticide treated nets.
The most recent available survey data is the Demographic Health Survey DHS 2013-14 carried out from November
2013 to February 2014 and published in May 2014. The DHS does not report directly on the above outcome
indicators. But it does give some indication of improved LLIN use by the groups we are interested in for this
programme:



In Equateur, LLIN utilization rate by U5 children increased from 2% in 2007 to 65% in 2013
There is also mention of an increasing use of LLINs by pregnant women, from 7% in 2007 to 60% in 2013
for the whole country, in the province of Equateur this rate increased from 7 % to 71%..
In Equateur province, the DHS concluded that the ownership of LLIN has reached 83% and then
exceeded the national objective expected to 80%.
On the logframe outcome indicators, the most recent data we have is from the post-campaign survey carried out by
Kinshasa Public Health School in September 2013 six month after the mass distribution. It demonstrated the
following results:
Table 1: Post campaign findings
Coverage Indicators
Before
distribution(2011)
Percentage of households with 76.0%
After
distribution(2013)
87.2%
MILD suspended
Percentage of pregnant women 39.4%
who slept under LLIN the night
before the survey
Percentage of children under five 29.9%
who slept under an LLIN the night
before the survey
70.0%
79.9%
By considering the findings from these two surveys with similar results even if they did not use the same
methodology, two indicators out of three for the outcome are already reached. We believe that the project therefore
remains on track to achieve its overall outcome.
Overall output score and description
The project’s performance is measured by the following outputs :.
Output title
Overall output Impact weight
score
comments
1.LLINs distribution
A
65%
2.Behaviour change communication A
(malaria prevention)
3.Monitoring and evaluation
B
4.Health system strengthening
A
15%
Output moderately did not meet
expectation
Output met expectation
10%
10%
Output met expectation
Output met expectation
Overall, the programme has scored an A (outputs met expectation) as all outputs were implemented and the
majority of their indicators have met expectations.
1. LLINs distribution through routine channels: Up to the end of December 2014, routine distribution of LLINs to
beneficiaries was scaled up throughout 42 health zones and resulted in the distribution of 279,317 LLINs to the
targeted beneficiaries against a milestone of 295,000.
2. Behaviour change communication: Interest and awareness was raised as how to prevent malaria. Intensive
Communication activities were carried out during the reporting period ranging from mass media (radio spots and
posters) to Inter Personal Communication during home visits, Antenatal Care (ANC) and immunization activities
Women groups, churches and mosques were also used as a means for social mobilisation and sensitisation.
3. Monitoring and evaluation: Supervisions were carried out by health zones staff that in turn were supervised by
both the district and provincial level of health officials. For the remaining time of the project, there is a need for
PSI to reinforce and improve the number of monitoring visits held at health zone and district level given the
poor performance against these indicators.
4. Health system strengthening: The training of actors was completed in all the targeted health districts. The
project was officially launched by the Governor of Equateur province in the presence of DFID DRC who handed
over 46 lap top computers, 46 printers to improve quality data collection, analysis and storage by the health
system and 585 bicycles to facilitate supervision activities carried out by head nurses.
Key challenges

Due to the poor conditions in rural areas including lack of adequate sleeping places in homes and problems
caused by the type of bed (wooden platform with rough edges), the lifespan of LLINs is reduced and cannot last
for three years as recommended by WHO.

The logistics of operating in Equateur are very difficult. Several health areas are located alongside the Congo
river with no communication network coverage and are hardly accessible. The poor conditions of the road make
any kind of movement limited.

The two health facility channels recommended by PNLP for the routine distribution of nets to pregnant wormen
are antenatal attendance and use of facilities in childbirth. In Equateur, it is noted that a significant number of
pregnant women do not attend antenatal care though they do use health facilities for childbirth. This limits the
opportunity for routine distribution to this group.
Key lessons
The assessment of the Equateur context, local opportunities and constraints lead to the following lessons:
 To maintain the high level of bed nets coverage after the mass campaign (universal access) by using routine
channels, there is a need to implement this approach in both private and public health facilities instead of relying
only in the public health facilities.
 To reach each vulnerable population with the routine approach, it was noted that a significant number of
pregnant women do not attend antenatal care but deliver in health facilities. Provision should be therefore taken
to supply this group of beneficiaries during delivery period.
 These two above lessons comply with WHO advice to each National Malaria control Programme to develop its
own net distributions strategy based on analysing the context of its local opportunities and constraints, and then
identify complementary distribution mechanisms. Further innovative solutions may be needed where access
and/or quality of antenatal care and Expanded Programme on Immunisation services are inadequate.
 Although mass communication through radio spots is useful to increase LLIN use, it is more appropriate for
urban areas, while Interpersonal communication and home visits are necessary to increase the use of bed nets
in rural settings where the greater population are found.
 To improve quality data collection and timely reporting by health personnel, operation support should be provided
using a performance based motivation method.
These lessons will be shared with all malaria stakeholders in country through regular meetings held by the malaria
network under the leadership of the PNLP,
Key actions

DFID and PSI started discussions with the PNLP on the current prevention approaches used in country based
on the lessons learnt from this project and will use future key findings from the operational surveys carried out
through this project to help update DRC prevention approaches by the end of the first semester 2015. The
topics of these surveys are the following: the durability of LLINs in the DRC context; the determinants of LLINS
use and non-use among the population in DRC; a review of the first cycle of LLINS mass distribution campaign
in DRC.

PNLP should update the routine approach and look for additional delivery mechanisms in the country based on
the Equateur experience to be shared by PSI by the end of June 2015

PSI should intensify Interpersonal communication by including more community health workers into the project,
and encouraging home visits to increase the use of LLINs, from now until the end of the project.

PSI should also review the number of community workers required at health area level based on the size and
geography of each health area by March 2015.

Due to inaccessibilty of remote health areas, PSI should also increase the number of monitoring/ evaluation staff
to ensure the good quality of data collection by March 2015.
Has the logframe been updated since the last review?
No, the log-frame was not changed since last annual review in February 2014 but was updated in conjunction with
PSI/ASF as part of the previous annual review process to reflect the additional activities agreed as part of the costextension granted in October 2013. This change was not considered in the last review as the routine activities were
not yet implemented.
Additional Key Points
In addition to the points raised above, the baseline of key indicators should be updated by considering the finding
from the recent DHS 2013-2014 before the end of March 2015.
Summary of responses to issues raised in previous annual reviews
The routine approach used in this project will contribute to maintain the bed nets coverage reached with the mass
distribution and will protect the DFID investment in the province.
The main recommendations of the last annual review were linked to the mass campaign distribution, especially the
monitoring of the bed nets use through pre and post campaign surveys as the hang up activities were cancelled. The
benefit of the home visits carried out by community health workers is to encourage population to hang up the bed
nets and to use it correctly. Two surveys are planned this year to assess the duration of use of a LLIN by households
in DRC and determine factors that might prevent effective use of LLINs in DRC.
The last recommendation focused of the evaluation of the most effective medium in reaching members of the
population, the interpersonal communication used in the routine distribution? is judged to be more effective as it
allows discussion between community workers, health staff and beneficiaries and contributes to increase or maintain
the behaviour change.
Recommendations
Two health districts where the project is implemented have not yet received funds for a second cycle of mass
distribution according to WHO recommendations. We will therefore need to consider what further action we or others
could take which might help protect our investment and maintain health impact in the province while PNLP is
looking for a funding donor.
DFID, PSI and PNLP will use the findings of the ongoing survey linked to the use of LLINs to update the national
strategy on malaria prevention in the second semestrer of 2015 .
PSI and PNLP should explore other mechanisms for the delivery of LLINs during routine distribution to sustain
universal coverage in the second semester of 2015 .
With the challenging environmnent of work in Equateur, it is important for PSI to increase the capacity of its staff by
recruiting two or three additional staff to ensure a good geographical coverage of all the health districts at the
same period and data collection.
PSI should update the logframe by considering the recent DHS result as baseline in March 2015. .
PSI should focus more on interpersonal communication in rural areas and increase the capacity of community
workers to give key messages linked to the maintenance of bed nets by March 2015.
DFID should work with PSI to improve the financial forecast and increase accuracy before the new financial year.
C: DETAILED OUTPUT SCORING (1 page per output)
The following output will be scored according to the achievement against milestones for each output indicator.
Title
LLINs distribution
Output number per LF
1
Output Score
A
Risk:
Low
Impact weighting (%):
65%
Risk revised since last AR?
no
Impact weighting % revised Yes from 70% during
since last AR?
the mass campaign
Indicator(s)
Milestones
2014
Number
of
LLINs 295 000
distributed through routine
channels
Number of health facility 1 725
providers trained for LLIN
routine distribution.
Progress up to December 2014
comments
279 317
Moderately did not meet
expectation (94%)
1 731
Met expectation (100%)
Despite the delay in the implementation of routine distribution due to the international procurement and transportation
of bed nets that took 8 months, the long process to recruit local staff in Equateur and, the outbreak of Ebola in
Tshuapa district; the project has made big efforts and has distributed 279,317 against the milestone of 295,000
through the classic antenatal care and immunizations activities in private and public health facilities.
During the implementation, it was observed that significant number of Pregnant women did not attend antenatal
care but come to give birth in health facilities. This led the project team to decide, in collaboration with PNLP, to
consider the delivery period as a complementary chanel mechanism of routine distribution in the province. In total,
169,251 bednets were distributed through ANC channel and 110,066 during immunization services.
Trainings on routine distribution, LLIN quantification, use of supervision tools, data collection, and data analyses,
were provided to 132 members of the health zones teams and also 799 community health workers (PresiCOSA) and
800 head nurses. In total 1,731 health providers were trained.
While visiting the rural areas in Equateur, we noted that the type of bed (wooden platform with rough edges) used
leads to a fast ripping of nets which results in a short lifetime of LLINs. With the reality of this Congolese context : is it
realistic for PNLP to respect the time frame of 3 years to renew LLINs distribution? Is the combination of campaign
and routine sufficient to maintain the coverage or do we need to find additional delivery mechanisms to ensure the
full coverage? We are planning to use the findings from the ongoing studies (including lessons learnt from the first
cycle of bed nets distribution in DRC and the durability of bed nets) to respond to these questions.
Output Title
Behaviour change communication
Output number per LF
2
Output Score
A
Risk:
Low
Impact weighting (%):
15%
Risk revised since last AR?
No
Impact weighting % revised no
since last AR?
The performance of this output was measured by two indicators: the first indicator concerns radio spots on malaria
prevention in general with a particular accent on the correct use of LLINs. The second indicator measures radio
programmes where invitees talk about the benefit of protecting pregnant women and U5 children from malaria by the
correct use of LLINs and where they were distributed.
Indicator(s)
Milestones 2014
the number of radio spots 12 144
broadcast on malaria prevention
Number of radio programme on 264
malaria prevention organized at
health zone level
Progress
up
December 2014
12 621
172
to Comments
Met expectation (104%)
Substantially did not
meet expectation (65%)
Intensive Communication activities were carried out ranging from mass media (radio spots and posters) to Inter
Personal Communication during home visits, Antenatal Care (ANC) and immunization services. Women groups,
churches and mosques were also used as means for social mobilisation and sensitisation in order to increase the
correct use of LLIN.
While the sensitisation concerning malaria prevention continued in the all targeted health zones, radio programmes
on LLINs routine distribution was halted in the12 health zones affected by the Ebola outbreak. The outbreak
prevented the provision of bednets in 12 health zones until the end of the quarantine, in November 2014.
The sensitisation boosted the utilisation rate of ANC and immunization services in targeted areas. As a result, 2,366
health talks were carried out during the reporting period, 60,385 pregnant women were recorded having attended ANC
health talks on malaria prevention, 63,337 caretakers who attended immunization services health talks and 32,428
households visited by community health workers. Moreover, social mobilization activities continue in the form of
announcements in churches, mosques, women group gathering.
Output Title
Monitoring and evaluation
Output number per LF
3
Output Score
B
Risk:
low
Impact weighting (%):
10%
Risk revised since last AR?
No
Impact weighting % revised Yes from 15% during
since last AR?
the mass campaign
Indicator(s)
Milestones 2014
Number of monthly monitoring visits
hold at health zone level,
Number of quarterly monitoring visits
hold at district level,
Monthly completion of health facility
reports
Monthly submission of health facility
reports ,
Monthly completion of health zone
reports
Monthly submission of health zone
monthly reports
504
Progress
up
December 2014
172
16
6
80%
85%
80%
100%
80%
85%
80%
100%
to Comments
Substantially did not meet
expectation (34%)
Substantially did not meet
the expectation (38%)
Moderately
exceeded
expectation (106%)
Substantially exceeded
expectation (125%)
Moderately
exceeded
expectation (106%)
Substantially exceeded
expectation (125%)
As initially planned , each health heath zone among the 42 health zones targeted by routine distribution had to carry
out one monitoring visit per month while each of the four health districts had to carry out one monitoring visit per
quarter in order to ensure the smooth running of the project.
The underperformance of some indicators is explained by the following factors : the routine distribution started only
in June 2014 for Mongala district (12 health zones ), in August 2014 for Mbandaka district (3 health zones),
September 2014 for Equateur district (15 Health zones ) and finally in December 2014 for Tshuapa district (12
health zones where Ebola outbreak happened. Beside this, PSI has not been effective in the startup of routine
activities, primarily in the deployment of bed nets from the warehouse to the targeted health zones , training for
health and community workers considered as pre-requisite before starting supervision, and finally the recruitment
process new staff was long and took more time . Despite this, health teams were motivated to perform well on other
indicators by the support the project provided. This support consists of IT equipment, monthly running costs and
bicycles for monitoring and evaluation activities (details in output 4).
For the remaining time of the project, there is a need for PSI to reinforce and improve the number of monitoring visits
held at health zone and district level given the poor performance against these indicators.
Output Title
Health system strengthening
Output number per LF
4
Output Score
A
Risk:
low
Impact weighting (%):
10%
Risk revised since last AR?
n/a
Impact weighting % revised n/a
since last AR?
This output has been added as a result of the project’s extension to cover health system strengthening to increase
the provincial health official’s capacity to monitor and supervision activities and will be considered for this annual
review.
Indicator(s)
Milestones 2014
Number of Health zones targeted 42
from the project area that been
equipped with computer hardware
Proportion of health zones having 100%
received supervision support,
Proportion of health zone offices 80%
having received supervision visit from
health district staff once per quarter
Proportion of health facilities having 7 5%
received supervision visit from health
zone staff once per month
Progress
up
December 2014
42
71%
71%
100%
to Comments
Met expectation (100%)
Moderately did not meet
expectation (71%)
Moderately did not meet
expectation (89%)
Substantially exceeded
expectation (133%)
Efforts have been taken to continue to strengthen the health system by providing training and supervision as well as
supporting for operations for the efficient running of activities by provincial, district and health zones teams.
Each health zone has received a laptop computer + printer to improve quality data collection, analyses and storage.
Health facilities nurses received bicycles to improve supervision activities.
Operational supports provided monthly by health zones after a presentation of activities and data consolidated
reports.
These contributed to the improvement in the supervision activities although because of the delay in the project start
the 2014 milestone to for the number of supervision visits was lower than expected.
D: VALUE FOR MONEY & FINANCIAL PERFORMANCE
Key cost drivers and performance
Commodities constitute the key cost driver: as there is no local market for LLIN in DRC, PSI/ASF our implementing
partner launched a competitive tender for the procurement and international transport of LLINs and the contract was
signed with Vestergaard Frandsen Group South Africa. This process allowed PSI to procure 582,574 LLINs
representing 95.5% of the LLIN needed to cover the project period in the 42 Health Zones, 4.5 % of the project needs
were covered by the remaining stock of the mass campaign. The unit cost paid by PSI for two-place LLINs was
$2.53, lower than the budgeted cost of $2.7 per LLIN, resulting in a saving of $98,994.
Cost of transporting commodities has been another key cost driver, the remoteness of the locations in Equateur
makes travel and transportation of materials very expensive. There are different layers in transporting commodities:
International shipping from manufacturer in South Africa to DRC entry point (Matadi); from Matadi to PSI central
warehouses (Kinshasa) by road; from Kinshasa to PSI provincial warehouses (Equateur/Mbandaka) by boat; from
Mbandaka to different health zones by road or boat and finally from health zones to health facilities by car or bicycle.
Table 2: Project costs by output and category
Spend (October 2013PSI Budget category
February 2015)
Commodities (LLINs)
£1,061,501
Sampling and testing
£1,373
£91,098
Output1: LLINs Shipping and handling
Training
£89,321
distribution
Procurement fees
£42,460
Output
2: Promotion and Advertising
£19,356
Behaviour
change
Communication and Education
£63,671
Research and evaluation (studies)
£61,911
Output 3: M&E
Travel and subsistence
£274,342
£22,881
Output 4: health Consultants
Equipment
£114,339
system
strengthening
Sub awards (operating cost – health
districts and health zones)
£65,762
Staff
Personnel and fee rate
£185,053
Office
Other direct cost
£121,226
Management
Administrative fee
£129,998
TOTAL PROJECT COST
£2,344,292
Output
% of total project
expenditure
55%
4%
14%
9%
7%
5%
6%
100%
In total , 82% of the budget was spent on programme delivery and health system strengthening, 11% on PSI office
and management fees and 7% on staff.
VfM performance compared to the original VfM proposition in the business case
This project memorandum predates DFID Business Case, thus does not have the same VfM measures. A cost and
time extension that was approved in October 2013 (Quest 4212123) set the following comparators:
Table 3: Mass vs routine distribution unit cost
Province
Coverage
Mass distribution in 4.2m LLINs for 8.5m people
Equateur
Total cost
Unit cost*
Comments
£20m
£4.58
Mass distribution with
a limited time for the
campaign
Routine distribution
through
health
services over 2 years
Equateur extension
609,616 LLINs for 894,104 £3.9m
£5.99
pregnant
women
and (excluding
children under 1
£300k for
operational
research)
Mass distribution in 4.4m LLINs for 7.2 m people
£20m
£4.57
Kasai Occidental
Mass distribution with
a limited time for the
campaign
*The unit cost includes the price of a net plus procurement fee, transport and distribution cost.
The logistics of operating in Equateur are extremely difficult, with chronically limited transport, infrastructure and
communications network. The road infrastructure is limited and in very poor condition, exacerbated by constant rain making any kind of movement extremely hard. Any imports arrive by river (4-5 weeks from Kinshasa) or by air to
Mbandaka. Several health areas are located alongside of the Congo River with no communication network coverage
and are hardly accessible. Despite the challenging context in Equateur, the extension represents value for money,
and is expected to achieve a unit cost of £5.99. The number of expected malaria episodes averted through LLIN use
by pregnant women and children less than one year old would result in more cost effective and significant health
impact than that associated with the treatment of malaria episodes in absence of LLIN use.
AS DFID primary health care project (ASSP) is also implementing routine distribution within the supported health
zones, it will be important to try to compare the unit cost in both of DFID supported programme when data become
available.
Assessment of whether the programme continues to represent value for money
The routine distribution of LLINs is expected to maintain the impact of the mass distribution for longer, by
continuously replacing LLINs over time, reinforcing and maintaining behaviour change, and strengthening the health
system by providing training and supervision. The intervention will be provided until 2015, when the next mass
distribution of LLINs in Equateur is scheduled to take place.
Although the unit cost of LLINs for this extension is higher than the £4.58 achieved by PSI for the mass distribution in
Equateur, this is not unexpected, as routine distribution takes place over a longer time period and is less able to
achieve scale of economy than mass distribution. This observation is consistent with evidence from Uganda
demonstrating that the delivery cost of bed nets is higher through antenatal care than through mass campaignsiii .
The higher unit cost may at least be partly offset by additional impact per net distributed. Firstly, through routine
distribution, LLIN delivery will be targeted towards those most vulnerable to malaria, i.e. pregnant women and
children under one year old. Secondly, the intervention is expected to slow the rate at which the coverage achieved
by the last mass distribution in Equateur will decline over time, thereby prolonging and protecting its impact.
There are limited data available on the unit cost of routine distribution elsewhere which would allow us to benchmark
the figure of £5.99. Furthermore, differences in methodology mean that in general, where unit costs of LLIN
distributions are available, they are difficult to compare meaningfully.
This has led to the authors of one review of the cost of LLIN distribution to observe that: “The cost of different ITN
delivery strategies is important when deciding which ones to scale-up, yet it is one of the knowledge gaps remaining
to be filled. Many strategies have not been costed at all and only some of the existing cost-estimates have been
derived using appropriate methods. Well-conducted studies have often used outputs that are difficult to compare”iv .
In view of the limited evidence for the relative cost-effectiveness of different delivery strategies for LLINs, PSI is now
carrying out four different studies on 1) the cost effectiveness of routine after mass campaign, 2) determinants of bed
nets retention and use, 3) lessons learnt from the first cycle of bed nets distribution in DRC and 4) the durability of
bed nets. The results of these studies are due by the end of the first semester of 2015 and findings will be shared
with PNLP in order to review or update the current strategy for LLINs distribution in DRC. However, the project is
operating within the estimated cost and there is no fear of an overspend in the remaining project’s lifetime.
Quality of financial management
Table 4: Extension budget burn rate
Financial year
11/12 & 12/13 Mass
distribution
Routine distribution
Forecast/budget
£20m
Spend to date
£19.8m
%
99
£4.2m
£2.3m
55
13/14
14/15
£1.6m
£2.4m
£1.6m
£1.3m
100
54
15/16
2011-2015 Total budget
£0.2m
£24m
£22.7m
95
Comments
Remaining 1% included in
the extension
Routine intervention ends
in October 2015
Remaining £1.07m.
Discussion ongoing
whether this can be
transferred into 15/16
To date, the spend and forecast for financial year 2014/2015 accounts for 54% of burn rate but this has raised the
whole project’s spend to 95%. The reason of this underspend is two-fold: the delay in starting the implementation of
the project’s extension, the suspension of activities for up to 4 months in 12 health zones affected by Ebola and the
inaccuracy of PSI forecasts over the year. While the Ebola was unpredictable, PSI should have predicted the delay
that was caused by the recruitment of staff in Equateur, the purchase of LLINs and their delivery in Equateur and
forecast accordingly. While the project’s extension started in October 2013, the purchased LLINs were delivered in
Equateur in July 2014.
There was a 3-month delay between the end of the original LLIN distribution campaign project and the beginning of the
new routine distribution project. PSI had to close both its Mbandaka and Lisala offices and most of the project staff were
transferred to other LLIN distribution projects in Kinshasa and Province Orientale. This resulted in start-up delays, as PSI
had to recruit all new staff and identify new office and warehouses.
While strong sensitisation boosted the utilisation rate in ANC and immunization services (in health facilities), hence
increased the distribution of bednets to pregnant women and U5 children, some other activities were partly funded.
This is the case of research studies (costing around GBP 300k) planned in the last quarter of this year but to be
completed and then fully paid in the next financial year. Besides, 12 health zones affected by Ebola did not receive
running costs and trainings of health providers for four months during which they were under quarantine.
Due to 2025/2016 budget constraints, discussion is ongoing within DFID DRC health team on the transfer of
2014/2015 underspend to the following year. The remaining 5% should be expected to be spent in the 9 remaining
months before the project’s end. DFID is looking forward to working with PSI on forecasts’ accuracy. DFID and PSI
will need to agree a spending schedule for remaining activities which are: pay the remaining funds for studies,
transport of LLINs from PSI warehouses to health zones – health facilities, operating support to health districts and
health zones for monitoring activities and PSI staff salaries.
Date of last narrative financial report
Date of last audited annual statement
12 February 2015
June 2014
E: RISK
Overall risk rating: Low/Medium/High
Low
Overview of programme risk
During the reporting period, the health district of Tshuapa particularly the Boende health zone which is part of the
project experienced an outbreak of Ebola haemorrhagic fever leading to the declaration of quarantine in the Tshuapa
health district , this situation highly compromised the start of activities in the entire Tshuapa health district, ASF/PSI
put in place an Ebola prevention strategy which consists of continuous education for staff, and monitoring of staff
movement to avoid any infection,
LLINs leakage was experienced during the mass campaign in Tshuapa health district particularly, to prevent similar
situation, ASF/PSI opted to store in Mbandaka all LLINs destined for distribution in Tshuapa, Health zones in
Tshuapa will be supplied quarterly and the provincial NMCP and ASF will intensify joint supervision activities with
focus in Tshuapa. These LLINS were recoverd with the involvement of the provincial government one week after.
ASF/PSI has developed and put at the disposal of each zones and health centres, tools to track LLINs movement.
Monthly data on the balance between the number of LLINs received by each health zone and the number of LLINs
distributed to beneficiaries are recorded for better accountability.
An early closure of the project in March 2015 as initially planned with the RAR cut will present the following risks:
1.
Undistributed LLINs (about 300,000) will be left to provincial health officials with no guarantee of results
2.
The absence of PSI will increase the likelihood of interference of the provincial authorities in misuse of LLINs
3.
The lack of incentives might lead to a loss of motivation in district and health zones teams
It is likely that the two health districts supported by this current project will not benefit from the second cycle of mass
bed nets distribution due to the lack of financial funds , there is a risk of losing the benefit gained with the extension
that maintained the high coverage of bed nets.
Outstanding actions from risk assessment
Consider what actions we or others might take to project the benefit of our investment in the province.
Outstanding actions from due diligence
A comprehensive Due Diligence Assessment (DDA) was conducted with PSI DRC team in person and their Deputy
Regional Director over the phone. The DDA was signed off by DFID DRC Head of Office on 27 October 2014 (Quest
4706468). The following recommendations were made:
DDA recommendation
DFID to be advised of timing of Internal Audit visits
and consider requesting a meeting with the team to
better understand risk environment
PSI to include the risk matrix with updates and
future actions as part of their quarterly reporting
status
Outstanding:
waiting the visit of
PSI Internal Audit
Implemented. An
updated risk matrix
is part of six
monthly report
DFID to maintain their current practice of seeking Ongoing
confirmation of forecasts at regular intervals. And
also seeking to improve communication and
understanding with PSI finance team
Ensure that PSI’s recognised purchase and Implemented. PSI
distribution process are detailed in their financial sends
quarterly
and narrative reports. And that funds to contractors detailed financial
are clearly set out in reporting to DFID.
reports. Additional
information is also
produced on DFID’s
demand.
F: COMMERCIAL CONSIDERATIONS
Delivery against planned timeframe
The routine activities started with a delay for the following reasons: the approval of the extension of the project took
three months before being effective, in the meantime the office was closed in Equateur. PSI was obliged to recruit
new staff to start the project with a focus on local recruitment to promote local ownership of the project and to ensure
at least 30% gender balance in staffing. This process lasted for 4 months. During the implementation of this project,
with the outbreak of Ebola, the activities were suspended in one district for 4 months (in 12 health zones). However,
and in regard to the current performance compared to 2014 planned milestone, it is likely that with the available
means, the implementer will meet the end of project targets.
However, the £200k forecasted for this programme in 15/16 (due to the resource allocation round) will not be
sufficient to support the distribution of more than 300,000 LLINs planned for next financial year, we anticipate that
there is a need to look for a way to consider if there is space in the budget for the next year in order to continue the
implementation of the project.
Performance of partnerships
The project is implemented under the leadership of the National Malaria Control Programme (PNLP) and is
contributing to their objectives.
PSI is in regular communication with both government, provincial and central health stakeholders and authorities to
share relevant project documents and information, and to address concerns that have arisen over financial and
technical management, transparency and reporting at the provincial level.
Regular meetings are held between DFID, PSI and the National Malaria Control Programme staff at both central and
provincial level to evaluate progress on activities implementation.
This collaboration has helped PSI and PNLP to jointly develop alternative solutions to reach more beneficiaries by
including the private sectors facilities into the project and by tracking pregnant women who never attend ANC but
seek health facilities during delivery period.
PSI is also working with local transporters to move LLINs from PSI central and provincial warehouses to health
zones. PSI is also working with local radio stations to broadcast key messages about routine distribution, malaria
prevention and correct use of a LLIN.
Asset monitoring and control
Programme’s assets are those used in the previous mass distribution in the province of Equateur and a few ones
from the UNDP DFID funded project that was completed in the province. In particular, vehicles and motorbikes are
now used and in poor condition. PSI keeps good electronic and physical record of programme’s assets. The PSI’s
project manager reviews project’s assets inventory on a quarterly basis as per PSI guidance and DFID’s accountable
grant provision on assets. The updated assets list is sent to DFID as an annex to the narrative report every six
months. On a recent field visit, spotchecks were conducted by DFID team on assets used by PSI staff in Mbandaka
and those used by two health zones management teams in Mbandaka and Bikoro. DFID team was satisfied of the
level of asset management on the field.
DFID and PSI will agree on the future of usable assets before the project’s end.
G: CONDITIONALITY
Update on partnership principles
Not applicable
H: MONITORING & EVALUATION
Evidence and evaluation
There is no evaluation planned for this project as the post campaign survey carried out in 2013 has already
demonstrated the impact of the mass campaign, especially for the following indicators: the ownership of LLIN by
household in Equateur increased from 55.5% to 90.8%. The percentage of children under five who slept under an
LLIN the night before the survey rose from 29.9% to 79.9%. This high coverage is also confirmed by the recent
findings from DHS 2013-14 published in May 2014) The project has planned to carry out four operational research
studies in order to get evidences on malaria prevention strategies used in DRC and feed discussion aimed to
update the current approaches implemented in the country. Four tenders have been launched since October 2014 to
select research agencies which will then conduct the following studies:
a)
The determinants of LLIN use and non-use among the population in DRC: The main objective of this study is
to explore and identify the causes of non-use of LLINs and the expectations of beneficiaries
b)
The durability of LLINs in the DRC context: The objective of this study is to determine the sustainability
(physical integrity and persistence) of LLINs in the field to adapt the cycle and LLINs distribution arrangements in the
DRC.
c)
The cost effectiveness of the distribution of routine after campaign mass of LLINs (specific to Equateur
province): the objective of this study is to determine the unit cost of routine distribution in DRC and the level of
coverage and use of LLINs in the Health Zones with supported post campaign routine distribution of LLINs compared
to health zones without supported post campaign routine distribution.
d)
A Review of the first cycle of LLINs mass distribution campaigns in DRC: The objective of this study will be to
review the first round of mass distribution of LLINs campaigns that took place in the DRC since the first strategic plan
(2009) in order to draw lessons that can help further improvement of the next mass distribution campaigns in the
country.
The findings for these studies are expected at the end of June 2015 and will feed discussions on malaria prevention
strategies in DRC.
Monitoring progress throughout the review period
In collaboration with PNLP, provincial MoH, and key malaria partners, the programme has supported the
harmonization of existing routine LLIN distribution tools such as the beneficiary register, the LLIN inventory sheet,
stock reception and movement documents among health zones.
Routine monitoring data is collected on a monthly basis at the health facilities level and then transferred into a
monthly summary sheet submitted respectively to health zone level, and the health district level. A review of routine
monitoring data is conducted on a monthly basis at health zone level and quarterly basis at health district level.
ASF/PSI M&E staff work closely with government staff at each level of the health system to ensure quality of data
and contribute to reinforcing the data management system during regular and joint supervisions.
PSI and DFID team meet on regular basis ( each month) to discuss and update the progress of the project.
During our recent visit to Equateur (from19th to 22ndJanuary 2015), we met with various provincial authorities, the
governor, the provincial minister of health, Provincial Medical Inspector, the provincial coordinator of PNLP, the
heath zone management teams (equipes cadres des zones de santé) of Bikoro and Mbandaka, the communities
and health workers in the following health areas: Penzele, Botende,Bikoro and Mbandaka. All authorities
appreciate the impact of this intervention as it has boosted some indicators such as the rate of antenatal care (
ANC) and immunization coverage. By providing IT kits to each health zone and supporting training and supervision
in the these 42 health zones without any other external assistance, this project is judged to be really important
for the province and has a big impact on the strengthening of the health system after the closure of World Bank
project in the province.
The excellent collaboration between the implementing partner and health authorities is a key element that has
contributed to the effectiveness of the project as everybody is involved to address/or solve issues/obstacles
identified during the implementation, for example, the additional delivery mechanism of bed nets at birth delivery
and the integration of private facilities into the project are the outcomes of this kind of collaboration.
This annual review process consisted of the following components:
-Regular meetings with PNLP
-Monthly meetings with PSI
-Field visit to two health zones In Equateur (Mbandaka, Bikoro)
-Reviews of four financial and two narrative reports
-Feedback meeting with PSI, Health zones management meeting, health workers, community workers, and
beneficiaries.
i
Measure DHS ICF international, DHS2013-2014, Final report published in May 2014
Measure DHS ICF international, DHS2013-2014, Final report published in May 2014
iii Kolaczinski J, “Cost and effects of two public sector delivery channels for LLIN in Uganda”, published on 20 April
2010
iv Kolaczinski, J and Hanson K (2006). “Costing the distribution of insecticide-treated nets: a review of cost and
cost-effectiveness studies to provide guidance on standardization of costing methodology” published on line in
2006.
ii
Smart Guide
i