Community-Based, Continuous
Distribution of LLIN in Nasarawa State,
Nigeria
Albert Kilian, Emmanuel Obi
Tropical Health LLP
August 6, 2015
EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
List of Abbreviations
ANC
BCC
CD
CDD
CI
FCT
HF
HH
ITN
JHU
LGA
LLIN
PHC
PMI
UNICEF
USAID
WDC
WHO
Ante-Natal Care
Behavioral Change Communication
Continuous Distribution
Community Drug Distributor
Confidence Interval
Federal Capital Territory
Health Facility
Households
Insecticide Treated Nets
Johns Hopkins University
Local Government Area
Long-lasting Insecticidal Nets
Primary Healthcare Center
President’s Malaria Initiative
United Nations Children’s Fund
United States Agency for International Development
Ward Development Committee
World Health Organization
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
Table of Contents
List of Abbreviations ..................................................................................................................................... 1
Table of Contents .......................................................................................................................................... 3
Acknowledgements....................................................................................................................................... 3
Executive Summary....................................................................................................................................... 4
Background ................................................................................................................................................... 6
Study Site ...................................................................................................................................................... 6
Community Distribution ............................................................................................................................... 7
Distribution design .................................................................................................................................... 7
Implementation ........................................................................................................................................ 9
Evaluation Methods .................................................................................................................................... 11
Evaluation objectives .............................................................................................................................. 11
Evaluation design .................................................................................................................................... 11
Sampling and sample size ....................................................................................................................... 12
Data collection ........................................................................................................................................ 12
Data analysis ........................................................................................................................................... 13
Ethical clearance ..................................................................................................................................... 14
Results ......................................................................................................................................................... 16
The sample .............................................................................................................................................. 16
Result of community distribution ........................................................................................................... 17
Access to new nets.................................................................................................................................. 18
Net ownership......................................................................................................................................... 20
Equity aspects ......................................................................................................................................... 21
Behavior Change Communication .......................................................................................................... 23
Net use .................................................................................................................................................... 24
Discussion.................................................................................................................................................... 27
Conclusion and Recommendations ............................................................................................................ 28
Acknowledgements
This report 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 Agreements No. GHS‐A‐00‐09‐00014‐00 and AID-OAA-A-14-00057. The
contents do not necessarily reflect the views of PMI or the United States Government.
The implementation of the CDD distribution was carried out as part of the MAPS program while the
evaluation surveys were implemented through Malaria Consortium.
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
Executive Summary
This report presents the outcome of an evaluation of a community-based, push-pull system of LLIN
distribution in Nasarawa State, Nigeria. Households in selected areas of the State were encouraged to
contact their local Community Drug Distributor (CDD) if they felt they need new or additional nets to
protect their family from malaria. The CDD would then verify the need and if satisfied, issue a net coupon
against which the household could obtain a new LLIN from the nearest distribution point at a health
facility.
The community based distributions started in June 2013, 31 months after the last mass campaign and
continued for 10 months until the evaluation survey in April 2014. Data from the endline survey was
compared to the findings from a baseline survey undertaken in October 2012, 11 months after the
campaign. Both surveys were standard population representative household surveys with a cluster
sampling design. Targeted sample size for each survey was 1020 and sample achieved was 1015 and 1003
for baseline and endline respectively. The evaluation design was a before-after comparison with an
embedded “per protocol” comparison between households aware and not aware of the CDD scheme at
the endline survey.
The major findings can be summarized as follows:
 ITN ownership indicators decreased from baseline to endline, but at endline were twice as high
among households aware of the CDD distributions than those not aware, and the decline from
baseline to endline was small for the CDD households and statistically not significant. In detail the
indicators were
o Ownership of any ITN: baseline 63%; endline CDD 55%, non CDD 28%
o Owning 1 ITN/ 2 people: baseline 25%; endline CDD 17%, non CDD 6%
o Population access to ITN: baseline 45%; endline CDD 35%, non CDD 16%
 Program effectiveness was overall not very good with only 18% of households that were aware of
the CDD distribution getting a new LLIN through the system. The biggest loss was by people not
requesting nets because either nets or net coupons were out of stock (55% of non-registration)
or people did not understand the scheme (42%). Less than 2% said that they already had enough
nets. Considering only the steps from requesting to getting new LLIN the effectiveness was
significantly better with 52% and again losses were mainly due to logistical reasons with nets or
coupons out of stock. Willingness of people to redeem the coupon once given was very high with
93% effectiveness from getting the coupon to going to the distribution point.
 Equity of distribution showed almost perfect equity at baseline and was slightly pro-rich at endline
but less so in the CDD group compared to the non CDD group. Concentration indices were 0.05
and 0.12 for any ITN and population access, respectively, for the CDD group, and 0.13 and 0.15
for the non-CDD group.
 The proportion of respondents who had been exposed to any messages around ITN use in the last
six months was highest at baseline with 68%, but at endline was also significantly higher for
households aware of the CDD program (49% vs. 27%).
 The BCC linked to the CDD distributions contributed to a better net utilization with 49% of those
with access to an ITN using it at endline in the CDD group, compared to only 31% in the non CDD
group. However, ITN use was generally much lower in the dry season (endline) compared to the
rainy season (baseline), when 71% of those with access had used the ITN.
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
The conclusions from the findings are that
 A community-based push-pull distribution system can work well to reach households missed by
the campaign, those who did not get enough nets, or those that lost the ones they had, provided
the scheme is well advertised and the logistics of supply function smoothly
 These distributions do not oversupply households but help to supply just enough for all members
to use ITN
 There was very little overlap with other supply channels showing that these distributions
complement each other in reaching all households
 Community-based distribution in this setting is reasonably equitable and equity can be further
improved if the poorest wealth quintile is encouraged to request new nets
 BCC linked to the community-based distribution is an important contributor to enhance messages
on ITN use resulting in better utilization of nets by those with access
The following major recommendations can be made:
 Community-based distributions – like all other continuous channels – need to be started at least
within one year following a successful mass LLIN campaign which implies that preparations should
always start even before the campaign takes place
 Informing the population about the distribution scheme and carefully explaining how it works is
critical and must be emphasized during roll-out as this will a the most important step to achieve
high program effectiveness
 Special attention should be paid to involving the poorest households to ensure that they feel
encouraged to participate in the scheme
 Logistics systems need to function smoothly and all efforts should be made to avoid stock-outs of
LLIN and net coupons
 BCC messages supporting use of nets should always be incorporated in such distributions
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
Background
Following the dramatic scale up of LLIN distributions in Nigeria through mass distribution campaigns, it is
increasingly realized by the Roll Back Malaria Partnership that repeated campaigns are not the best
solution to sustain the achieved gains and that a comprehensive distribution strategy which includes
continuous distribution mechanisms is needed. The purpose of such continuous LLIN distribution is to
 Avoid decline of population coverage (and hence protection) to levels below the threshold of the
mass effect between repeated campaigns caused by the loss of nets through wear and tear
 To provide replacement nets as well as supply new families when and where this is needed and
to do this in an equitable and sustainable manner
Two principle approaches are possible in the implementation of continuous distribution. The most
common way is to use routine health services to give LLIN to persons at particular risk such as pregnant
women through ANC or children when they come for immunization. The eligibility to receive an LLIN is
defined exclusively by the attendance at the specific services and therefore these distributions are called
routine distributions in the strict sense. They can also been described as a push system.
The second approach consists of distribution mechanisms which are initiated by those who have a
perceived demand for nets and then gain access to a full-price or subsidized system. This can also be
described as a pull or demand-driven system and includes among others the classical social marketing.
A combination of the two would be a push-pull system where a certain amount of nets is pushed to a
certain point in the supply chain (hub) from where the net users can pull down nets according to their
demand and based on defined eligibility criteria.
In December 2010, nets were distributed in a mass campaign in Nasarawa state, where each
household/family received two nets. NetWorks Project designed and supported the implementation of a
community-based long lasting insecticidal nets (LLIN) distribution strategy, to help improve and sustain
net coverage beyond the mass distributions in all LGAs in Nasarawa state.
This community-led LLIN distribution strategy has two separate phases:
1) The push of LLIN to the storage/ health facility
2) The pull of LLIN by households, which requires two active steps by the household (supported by
adequate BCC)
 Visit to a Community Drug Distributor (CDD) to declare the need for an additional or
replacement net
 Visit to a LLIN storage hub (health facility) to redeem a LLIN coupon issued to the
household upon assessment of LLIN need by CDD. LLIN coupon is redeemed for a new
LLIN
Study Site
Nasarawa State was created in 1996 through a split from Plateau State and has 13 Local Government
Areas (LGA). It is located in the North Central zone of Nigeria bordering the Abuja Federal Capital Territory
(FCT) to the West, Tabara and Plateau States to the East, Kaduna State to the North and Kogi and Benue
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
States to the South (Figure 1). With a surface area of 27,117 km² and an estimated population in 2010 of
2,097,132 based on the 2006 census results and a reported 3.0% growth rate [4] the mean population
density is relatively low with 77 persons/km². Due to the multitude of ethnic groups in the state Nasawara
has been called a “mini-Nigeria” in this respect. The major ethnic groups include Eggon, Tiv, Alago, Hausa,
Fulani, Mada, Rindre, Gwandara, Koro, Gbagyi, Ebira, Agatu, Bassa, Aho, Ake, Mama, Arum and Kanuri.
While English and Hausa are widely spoken in the state, all the ethnic groups indicated above also have
their own languages.
Figure 1: Location of Nasarawa State and its 13 LGAs within Nigeria
NORTH WEST
NORTH EAST
NORTH CENTRAL
SOUTH WEST
SOUTH EAST
SOUTH SOUTH
Nasarawa State lies within the Guinea Savannah eco-geographical zone. Accordingly, overall rainfall is
moderate to high varying between 1300-1550 mm per annum. The rainy season lasts from April to
November with the peak of rains between July and October.
Community Distribution
Distribution design
Following meetings with the State authorities for Health discussions were held with key partners and
stakeholders (UNICEF, WHO) and departments of the State Ministry of Health (Onchocerciasis Control and
HMIS). This was followed by field visits to two LGAs (Kokona and Akwanga) including discussions with the
LGA health teams, visit of a health facility and discussions with a number of CDD. A one-day workshop
then presented the options the team had developed to the stakeholders and preferences and challenges
were discussed. Building on the consensus reached with representatives at all levels (State, LGA, Wards,
communities and the CDDs), the community distribution channel was designed with the aid of the
NetCALC tool.
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
The CDD distribution system:
 Builds on existing systems and mechanisms and supports or enhances these as much as possible
(integration).
 Makes adjustments where needed to take into account the specific characteristics of the nets
(e.g. their bulkiness) as well as aspects of use (need for a net culture and motivation to use)
 Complements ANC-based distributions as recommended by WHO and NMCP since this will
guarantee that pregnant women receive an LLIN as early in their pregnancy as possible without
having to wait for the next distribution period
 Is community-driven, requiring a pro-active role of households to initiate the process of obtaining
new or additional LLIN (push-pull system)
The NetCALC tool estimated the output that can be expected of various distribution channels (routine
services including schools or community or market based) and compared these with the calculated need
to sustain the defined target. Using data on access to services from the 2008 DHS such projections were
made for Nasarawa and results are shown in Figure 2. These suggest that even if ANC and EPI distributions
are used together with school-based distributions in primary and secondary schools, the target of 80%
LLIN household ownership could not quite be sustained. However, if ANC distributions to protect pregnant
women throughout their pregnancy were combined with a community-based distribution system (e.g.
through CDD), approximately 50% of all households would need to receive a net through the community
system each year, and the target of 80% LLIN ownership could be sustained. In such a scenario for 2012/13
about 58,000 LLIN annually would need to be channeled through ANC and 220,000 through the CDD
system.
Figure 2: Output from NetCALC for Nasarawa: light green line expected coverage from distributions; dark
green diamond ITN ownership at survey; blue line need of LLIN to sustain target of 80%; red lines different
continuous distribution scenarios
The Nasawara state community-based distribution was designed as a State-wide implementation,
comprising 13 LGAs and 147 wards, with each ward providing a good number of active CDDs based on the
population size. At the time of designing community-based distribution, it was estimated that each CDD
covered between 250-2,000 people during their routine drug-distribution activities. In the first year of
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
implementation, lacking consumption data to base LLIN allocations to the wards, the design team used
the NetCALC tool to estimate that a CDD covering 2,000 people would distribute approximately 200 LLIN
in the first six months, and 130 LLIN in the second six months.
Figure 3: Basic design of the community distribution system. HH= household, DC=development
committee, HF=health facility
Implementation
Microplanning
As micro-level planning for the community-based distribution continued beyond the design stage, it was
decided that a scaled approach would be used. The distribution began in four wards of each of the 13
LGAs, with an initial cadre of 260 CDDs and 52 health facilities (13 general hospitals and 39 primary health
care centers) serving as local net storage and distribution hubs. During implementation, the number of
wards reached by the CDDs gradually increased.
Stakeholders and RBM Partners conducted a micro-planning meeting that clearly delineated roles and
responsibilities. The micro-plan also produced implementation timelines, developed LLIN Coupon, health
facility register and summary sheets at various levels, quantification of LLIN need by LGA and a supervision
checklist.
Training
The trainings were partitioned into two parts. First, State-level training of trainers workshop for State and
LGA (malaria and onchocerciasis officers) and, secondly, LGA level cascade trainings for in-charge of PHCs,
CDDs and WDCs. A state-level training of trainers was held over a two-day period with two
representatives per LGA (Roll Back Malaria focal persons and the Neglected Tropical Diseases focal person
for each LGA). These 26 trainees in turn trained the five CDDs in each of the four selected wards of their
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
LGA (260 CDDs) and the in-charge/head of the 52 health facilities that would serve as the hubs for storage
and issuing of nets.
The cascade trainings brought together different caliber of personnel on a one-day basis on different days,
to train the CDDs and the health facility head involved in the distribution. The training gave an overview
of the LLIN distribution process through CDDs and how to complete the data collection tools, such as the
LLIN gap assessment form, LLIN Coupon, health facility register and summary forms. Trainees also
reviewed what messages to share with clients to health facilities to raise awareness about using LLINs and
how to obtain one through the CDD system. The cascade training approach also created a mechanism for
relaying important updates and feedback from the State Malaria Control Program through the LGA Roll
Back Malaria focal persons to the health facility staff and CDDs.
Mobilization and BCC
The pull mechanism of this strategy depends on the demand for nets by potential beneficiaries. Demand
generation activities have been conducted primarily through interpersonal communication directly with
community members by the CDDs, the Ward Development Committees, and community-based
organizations and volunteers involved with MAPS activities in Nasarawa.
Flow of activities:
a. LLIN are allocated monthly/quarterly to LGA and hubs based on expected need, prioritization and
LLIN availability, after the initial phase consumption vs. expected need will also be considered
b. Nets and other supplies are transported to hub
c. In parallel communities (and local leaders) are sensitized and reminded to select CDD where there
are no currently active ones
d. CDD are called for a one day training on the processes and given materials (LLIN coupon booklets,
assessment form booklet, registers and forms)
e. Communities are informed that during a given period, they can approach the CDD and express
their need for more nets
f. CDD will visit these households and assess the need based on household members and existing,
viable nets and give LLIN coupon(s). This can be combined initially with a prioritization (based on
clear criteria and an assessment aid) e.g. based on size of gap in household in order to ensure
settlements and families missed during campaign are served first without exhausting the net
supply. Once a steady state is reached (second year) this would no longer be necessary
g. Households take the LLIN coupon to the health facility (storage hub) or ward development
committee to receive their net(s)
h. Supervisors (PHCs, LGA) meet with CDD monthly/quarterly to discuss issues, collect summary
forms and issue supplies if needed
i. Summary reports from CDD and hub (distribution data) are sent monthly/quarterly to LGA and
State.
Distribution
The distribution started effectively in June 2013 and by the endline survey in April 2014 a total of 82,307
LLIN had been delivered to the distribution points. As shown in Figure 4, the monthly distribution was
highly variable with an initial peak August to October 2013 with monthly distributions between 7,000 and
9,000. This was followed by a low in November and December (approximately 4,000 per month) and
another peak in February and March 2014 with 14,000 and 16,000 per month.
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
The exact number of LLIN delivered through ANC are not known but can be estimated at around 20,000,
bringing the total LLIN delivered through public sector continuous distribution to around 102,000. This
figure represents 42% of the 245,850 originally earmarked for this purpose and about 27% of the annual
need to sustain universal coverage in Nasarawa State based on NetCALC projections.
Figure 4: Number of LLIN distributed by CDD up to the endline survey
Evaluation Methods
Evaluation objectives
The primary objectives of the survey was
1. To assess the outcome of two different approaches to continuous distribution, a community-based
scheme in Nasarawa State with respect to LLIN ownership and sustaining or achieving universal
coverage
2. To assess the level of net retention/attrition of campaign nets three years after the mass campaign
3. To assess the use of nets in general and LLIN in particular by different population groups
Secondary objectives of the survey were as follows
 Measure the equity in access to nets from various sources
 Obtain detailed information about net use and sleeping patterns in the family
 Evaluate the success of the IEC and BCC activities associated with the program
The research question was:

Did the continuous distribution of LLIN through schools or community drug distributors maintain
the household coverage achieved by the universal LLIN access campaign or even contribute to
closing the gap left by the campaign?
Evaluation design
The evaluation design was that of a before-after comparison through state representative, two stage
cluster-sampling household surveys. The baseline survey was undertaken in October 2011 and the endline
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
survey in April 2014. The timing with respect to the rains is shown in Figure 5. The baseline survey was
primarily designed as a post-campaign evaluation 11 months after the LLIN mass distribution. The endline
survey was specifically designed for the outcome evaluation of the community distribution and included
in the design a comparison between areas with and without continuous distribution of LLIN through CDD
in addition to the before/after comparison.
Figure 5: Annual rainfall pattern in Nasarawa State at 8.25° East longitude and the timing of the surveys
Sampling and sample size
Both surveys had a 60 by 17 design, meaning 60 clusters with 17 households each, for a total of 1,020
households targeted for each survey. The baseline survey had only a single domain and no stratification
while the endline survey included two domains: one comprising the areas targeted for CDD distribution
and one with those areas not targeted.
Sample size was calculated to detect a difference of at least 9 percentage-points between baseline and
endline survey estimates for ITN coverage if one of the data points is 50% and a 11-percent-points
difference within the endline survey between CDD distribution and non-distribution. The following
assumptions were underlying the calculations of sample size:
 Confidence interval 95% (alpha-error=0.05)
 Power 80% (beta-error=0.2)
 Design effect of 1.75
 Non-response rate of 5%
Data collection
Questionnaires
For data collection a pre-tested questionnaire was used. The primary respondent was the head of
household or his/her spouse, and the person who went to the distribution point for net collection (where
this was not the same person). The household module included questions regarding all existing mosquito
nets and these were inspected by the survey team provided permission was given. The household/net
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
module was followed by a questionnaire module for each child of eligible age in the household in order
to assess the full immunization coverage and this section was addressed to the caretaker of the children.
The household/net section of the questionnaire was identical with that used in the post-campaign surveys
following the stand-alone LLIN campaigns in Kano and Anambra states while the immunization section
was based on the respective questions used in the DHS questionnaire. The complete questionnaire used
is presented in the Annex.
Visual aids
In order to identify specific net brands and categorize them as LLIN the interviewers were provided visual
aids showing all currently available LLIN brand labels and packages. In case access to the net was not
granted to the interviewer the respondent was shown the visual aid and asked whether they could identify
the brand of the net. Similarly, examples of the net cards used in the distribution and samples of the
vitamin A capsules and the de-worming tablets used during the child heath campaigns were provided to
the interviewers to be shown to the respondent.
Teams and Training
Interviewers and supervisors were carefully selected to be culturally acceptable, to have good knowledge
of the local language, and to have experience in household surveys. Each team had one supervisor and
four to five interviewers. The week before the fieldwork, the field team was trained for four days. The
training covered the purpose and exact procedures of the interviews following the interviewer’s guide
and involved role playing as well as some pilot interviews.
Community Sensitization.
This phase took place early October 2011. Local authorities were contacted for approval to conduct the
survey. Visits were made to the relevant heads of settlements, and the purpose and procedures of the
survey were explained to them. In all cases, the heads of each settlement granted authorization and in
turn either personally notified the relevant heads of ward or referred the team to the heads of ward who
were also informed of the survey objectives and procedures. The community mobilization specifically
attempted to ensure that no further expectation of another distribution campaign after or during the
survey was created.
Interviews.
The interviews took place from October 24 to November 10. Each selected household was visited, and the
head of household or one of his or her adult dependents was interviewed. If no appropriate respondent
was found at the house, a new visit was scheduled later that day. At least three attempts were made to
reach a respondent before dropping the household without replacing it.
Quality control
At the end of each day, the team supervisor reviewed all questionnaires for completeness and possible
inconsistencies and ensured that missing information was corrected while still in the field. In addition,
spot-checks were performed on 12% of interviews conducted by each fieldworker.
Data analysis
Data entry was done using QPS software with double entry of all records. Both data sets were then
compared, and any discrepant records were verified using the original questionnaires. After the first stage
of cleaning, the data set was transferred to the STATA 11 statistical software package for further
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
consistency checks and preparation of data files. The final data files (household, member, net, and child
sections) were sent to the evaluation team for further processing.
Final analysis was done using STATA 11 software based on the previously defined outcome indicators
broken down by background characteristics, including place of residence (urban and rural), whether a
households had any children eligible for immunization i.e. under five years of age and socioeconomic
status (wealth quintiles). Sampling weights were calculated based on the probability of cluster and
household selection. All analyses were done adjusting for the cluster sampling by using the survey
command family in STATA.
The wealth index was computed at the household level using principal component analysis (PCA) [5]. The
variables for household amenities, assets, livestock, and other characteristics that are related to a
household’s socioeconomic status were used for the computation. All variables were dichotomized except
those of animal ownership where the total number owned was used. The first component of the PCA was
used as the wealth index. Households were then classified according to their index value into quintiles.
However, quintiles were calculates separately for urban and rural strata in order to adjust for rural-urban
differences in socio-economic status. For analysis of individual members of the household or nets the
quintile allocation of the household was applied. Concentration index and concentration curve (Lorenz
curve) was used to analyze outcome differences by wealth. Standard errors and confidence intervals for
the concentration indices were calculated using the formula suggested by Kakwani et al 1.
Responses related to questions on IEC/BCC where respondents were asked to choose on a scale were
recorded. For questions 47 to 52, response options were recoded to read 2 for “definitely could,” 1 for
“probably could,” –1 for “probably could not,” –2 for “definitely could not.” For questions 53 to 58, the
responses were recoded to read 2 for “strongly agree,” 1 for “somewhat agree,” –1 for “somewhat
disagree,” and –2 for “strongly disagree.” The recoding prevents distortion when computing the mean
because, in general, for scaled responses people tend to choose the highest score (“definitely could” or
“strongly agree”). After recoding all the questions, a mean score was computed to reflect the household
ability/willingness to take action to prevent malaria infection or household knowledge about malaria. For
questions on taking action, the households were then classified into two groups, the ones which are less
likely to take action (score equal or less than 0) and those which are more likely to take action (score more
than 0). For questions on knowledge, households were also classified into two groups (good knowledge
for a score more than 0 and poor knowledge for a score equal or less than 0).
Ethical clearance
Ethical clearance for both surveys was obtained from the Institutional Review Board of the Johns Hopkins
University, Baltimore, USA (baseline study number 3852; endline 5553) and the National Health Research
Ethics Committee, Abuja, Nigeria.
Individual verbal informed consent was sought from all respondents before interviews were conducted.
Before each interviewee was asked to give consent, the interviewer gave a brief description of the study
objectives, the data collection procedure, the potential harm to participants, the expected benefits, and
the voluntary nature of participation at all stages of the interview. In addition, consent was also sought
from community representatives (chiefs). Participants were informed of the possibility that a repeat
1
Kakwani NC, Wagstaff A, van Doorslaer E: Socioeconomic inequalities in health: measurement, computation, and
statistical inference. J Econometrics 1997, 77:87-103
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
interview may be conducted by a different person to ensure data quality. They were also ensured that
data would be kept confidential and would not be shared with non-project staff. Participants in the final
data set were rendered anonymous by removing the variable “name” and all other information within a
particular cluster that could help to identify individuals or households, and replacing these with a new
numerical identification number generated to uniquely identify the individuals and the households.
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
Results
The sample
The final sample for analysis was 1015 (99.5% of target) for the base line survey and 1003 (98.3%) for the
endline survey. The sampled population was 5323 at baseline and 4949 at endline with 95.3% and 98.0%
of the population having stayed in the house the previous night (de-facto population) respectively.
Table 1 provides an overview over some demographic characteristics of the two survey samples. None of
the indicators differed statistically significant between the two surveys 2.5 years apart, but the proportion
of households with any young children and female headed households differed by 6-7 percentage-points.
The proportion of children under five within the de-jure population was rather small compared to other
data from the area, but consistent between the two surveys.
Table 1: Demographic characteristics of sampled households
Indicator
Mean number of people per household
Mean age of head of household (years)
Households with any child <5 years
Households headed by female
Population under 5 years of age
Population under 15 years of age
Women age 15-49 currently pregnant
Estimate
5.0
40.7
47.1%
25.7%
13.4%
40.6%
6.5%
Baseline
95% CI
4.7 – 5.2
39.4 – 42.1
43.4 – 50.7
21.5 – 30.3
12.0 – 15.0
38.6 – 42.7
3.9 – 10.5
Estimate
5.0
40.0
55.4%
19.4%
15.6%
46.0%
7.8%
Endline
95% CI
4.6 – 5.5
38.4 – 41.6
48.2 – 62.3
14.4 – 25.5
13.5 – 18.0
43.5 – 48.4
5.5 – 10.6
Household access to safe drinking water increased from 58.1% (95% CI 44.4 – 70.6) to 71.2% (56.3 – 82.6)
but the difference did not reach statistical significance. In contrast, the availability of any kind of latrine
to the household remained unchanged with 60.5 and 61.4% respectively. Educational achievements of
the heads of household also did not differ between the surveys when disaggregated by gender as shown
in Figure 6. Finally, the household assets as presented in Table 2 were very much comparable suggesting
that overall the two surveys were representative of the population of Nasarawa State.
Figure 6: Educational level of heads of household by gender
Table 2: Assets of sampled households
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
Indicator
Radio
Television
Mobile Phone
Refrigerator
Any means of transport
Owns land for farming
Estimate
79.2%
41.0%
61.0%
10.3%
70.4%
79.0%
Baseline
95% CI
75.2 – 82.8
35.2 – 47.1
54.5 – 67.1
6.5 – 15.8
65.0 – 75.5
71.0 – 85.3
Estimate
72.8%
40.8%
65.8%
13.5%
73.9%
75.1%
Endline
95% CI
67.7 – 77.3
30.2 – 52.3
58.3 – 72.6
6.4 – 26.0
66.2 – 80.4
64.6 – 83.3
Result of community distribution
Among all sampled households only 32.2% (95% CI 26.6, 38.4) could recall that the community distribution
through CDDs had been announced in their community. Somewhat surprisingly, this did not statistically
differ between areas that had been designated for CDD distribution (30.6%) and those not (33.1%, p=0.6).
Recalling an announcement of the distribution scheme also did not vary by urban-rural residence,
educational status of the head of household or the wealth quintile. It was higher, however, for households
that owned any mosquito nets (47.9%) compared to those that did not (23.1%, p<0.001). Among the 60
clusters of the survey only in 19 (32%) did more than 40% of the sampled households recall the CDD
distribution announcement and only in 8 (13%) more than 50%. Interestingly, among those household
respondents who did recall an announcement of the CDD scheme, 59.1% (48.1, 69.1) said that they also
had informed others about it.
Only 34.5% (18.8, 54.5) of those aware of the CDD distributions ever requested a new ITN from the CDD,
which was the largest step of program effectiveness as shown in Figure 7. Reasons for not requesting are
shown in Figure 8 and in 54.6% there were either no nets or the CDD could not be found. In another 41.7%
people said they had not understood how the program would work. Only 1.2% of respondents stated that
they already had enough nets.
Figure 7: Program effectiveness from knowing about the CDD scheme to getting a new LLIN
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
Of those requesting a new ITN, 71.8% received a coupon from the CDD, and for those not getting one 92%
said that the CDD had run out of coupons. The step from getting a coupon to going to the distribution
point was highly effective with 92.7% of respondents doing so. But at the distribution point again only
71% of those going actually got a net, and the reasons for not getting one were 82% “no nets in stock”,
5% “store was locked” and the rest did not recall the reason. This resulted in a program effectiveness of
51.4% if the steps from requesting to receiving are considered.
Figure 8: Reasons for not requesting a new ITN from CDD among those aware of program
Access to new nets
Overall 16.5% (11.9, 22.4) of sampled households still owned a net from the last campaign, and 26.5%
(20.9, 32.9) had received any new nets after the 2010 mass campaign. The different sources of these new
nets are shown in Figure 9 for all households and the relative share of sources among those with any new
nets. If the recall of respondents is correct, there were considerable distributions directly through health
facilities but outside the ANC distributions. If direct facility and CDD distributions are taken together they
comprised the largest fraction with 18.5% of all sampled households and 68.5% of those who received
any new nets since the campaign. It is noteworthy that the commercial sector was the second largest
source and as these were all LLIN it is very likely that they were nets leaked from the campaign or other
public distributions. Households with nets through ANC services were 4.5% overall and 12.8% of those
with any new nets while 4.2 and 16.0% respectively had obtained nets from family or friends.
Access to new nets did not differ by urban-rural residence, family size or wealth quintile but differed
significantly by the status of participation in the previous mass campaign as shown in Figures 10 and 11.
In addition to being more likely to getting a new net, households that said they had received a net from
the campaign also showed a different pattern of the source: while CD was the dominating source for
campaign net owners, family and the market were much more important for those who had not received
a campaign net. The results show that with the exception of direct facility and CDD distributions which
were used similarly, there was very little overlap between CD channels and CD channels were clearly more
used by households that already had the experience of the campaign.
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
Figure 9: Households obtaining any new ITN since campaign and the source
Figure 10: Source of new nets by mass campaign participation
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
Figure 11: Sources of new nets by campaign participation and type of distribution channel
Net ownership
The trend in ownership of any ITN and those from the mass campaign between October 2011 (campaign)
and April 2014 is shown in Figure 12 and the detailed ITN indicators of ownership and intra-household ITN
supply are presented in Table 3. The data show clearly that in spite of the very late start of the CDD
distribution more than two years after the campaign, the ITN ownership rate was at endline was more
than twice as high compared to households not aware or included in the CDD distribution and this
difference was statistically significant. Among households aware of the CDD distribution in their
communities, the ITN ownership indicators were also only marginally lower than at baseline, meaning
that the post-campaign situation had almost been sustained. As shown in Table 3 this happened without
over-supply of households and the category that improved most was that of households with exactly the
right amount of nets.
Figure 12: Trends in ITN and campaign net ownership since the 2010 campaign
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
Table 3: ITN ownership indicators and intra-household ITN supply
Indicator
HH owns any ITN
HH owns one ITN per two people
Population access to ITN in HH
Intra-household ITN supply
No ITN
Less than 1 ITN/3 persons
1 ITN/3 persons
1 ITN/2 persons
1 ITN/ person or more
Baseline (Oct 2011)
Estimate
62.5%
24.8%
45.3%
95% CI
54.9 – 69.6
20.2 – 30.0
39.3 – 51.4
37.5%
21.1%
16.7%
18.7%
6.1%
30.4 – 45.1
17.4 – 25.2
12.8 -21.6
14.8 – 23.4
3.8 – 9.7
Endline (April 2014)
Aware of CDD
Not aware of CDD
Estimate
95% CI
Estimate
95% CI
54.6%
46.5 – 62.5
28.3%
21.3 – 36.6
16.6%
11.1 – 24.0
6.2%
3.3 – 11.2
34.5%
28.8 – 41.2
15.7%
11.8 – 20.5
45.4%
29.4%
8.6%
16.0%
0.6%
37.6 – 53.5
20.0 – 41.0
5.0 – 14.5
10.6 – 23.4
0.2 – 1 .4
71.7%
16.2%
5.9%
5.6%
0.6%
63.5 – 78.7
11.9 – 21.8
3.8 – 8.9
2.8 – 10.6
0.3 – 1.3
Equity aspects
The equity of distributions was first assessed by the concentration or Lorenz curves for ownership of any
ITN and the population access to an ITN within the household (Figure 13). These curves plot the cumulative
distribution of wealth quintiles in the overall sample against the cumulative distribution of wealth
quintiles in the sub-sample of interest (here ITN ownership). If these distributions are exactly the same,
i.e. if there is perfect equity, the resulting curve is identical with the equity line. A curve below (or to the
right) of the equity line indicates a pro-rich inequity and above (or to the left) a pro-poor inequity. As can
be seen in Figure 13 equity at baseline, i.e. approximately 11 months after the mass campaign, was highly
equitable. At endline the curves suggest a slight pro-rich inequity for ownership of any ITN which was,
however, less pronounced among households aware of the CDD distribution. For population access to
ITN within the household the curves were similar, but the pro-rich inequity somewhat more pronounced
and the difference between CDD and non CDD distribution areas was less.
Table 4 shows the equity situation expressed as concentration indices which is just a composite way to
express the data of the Lorenz curve in a single value. Here 0 represents perfect equity, -1 maximum propoor inequity and +1 maximum pro-rich inequity. As can be seen, the indices show the same situation as
described above.
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
Figure 13: Concentration curve (Lorenz curve) for any ITN ownership and population access to ITN
Table 4: Concentration indices for net ownership and access
Baseline (Oct 2011)
Indicator
HH owns any ITN
Population access to ITN in HH
Index
95% CI
0.012
-0.001
0.001 – 0.024
-0.019 – 0.017
Endline (April 2014)
Aware of CDD
Not aware of CDD
Index
95% CI
Index
95% CI
0.050
0.126
-0.014 – 0.114
0.086 – 0.167
0.121
0.152
0.055 – 0.187
0.110 – 0.194
In order to explore which part of the distribution process caused the inequity observed, the three phases
of knowing about the CDD scheme, requesting a new LLIN, and obtaining it from the distribution hub were
plotted against wealth quintiles (Figure 14). This shows that the major problem was that the poorest as
well as the richest did not request new nets as frequently as the “middle class”.
Figure 14: Process of getting net from CDD by wealth quintile
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
Behavior Change Communication
Respondents were asked whether they had heard or seen any messages on mosquito nets and their use
in the last six months. The proportion that confirmed this was much higher at baseline 11 months after
the campaign (68%) compared to the endline survey (Table 5), but at the endline households also aware
of the CDD distribution had significantly higher BCC exposure (49%) than those unaware (27%, p<0.05).
On average respondents that were exposed to BCC recalled between one and two different information
sources (mean 1.4) and this did not differ between the surveys or the CDD distribution and nondistribution. The information sources mentioned are presented in Figure 15 and show that 11 months
after the campaign, health workers were the most common source of net related messages while in 2014
messages through radio were most common. There was a strong correlation between the number of
information sources mentioned and the number of messages recalled and this was true for both surveys
(p<0.0001). The most commonly recalled messages are shown in Figure 16. They were generally similar
between the surveys with messages on net use and hang-up recalled most, but at the endline survey
messages on net care and the malaria prevention aspects were more often recalled than at baseline. This
latter is explained by the Nasarawa net care and repair BCC campaign that had been ongoing in 20132014, in portions of the state.
Table 5: Exposure to BCC messages last six months and household attitude towards net use
Indicator
Heard any message about nets
Discussed net use in family
No BCC exposure
BCC exposure
Intends to use nets most nights
No BCC exposure
BCC exposure
Baseline (Oct 2011)
Endline (April 2014)
Aware of CDD
Not aware of CDD
Estimate
95% CI
Estimate
95% CI
48.5%
39.4 – 57.7
26.6%
19.8 – 34.8
Estimate
67.7%
95% CI
60.2 – 74.4
40.5%
81.8%
33.0 – 48.5
76.6 – 86.0
63.3%
81.1%
52.0 – 73.3
69.2 – 89.2
29.2%
58.7%
20.8 – 39.3
42.8 – 73.0
68.0%
85.8%
56.2 – 77.9
81.2 – 89.1
47.2%
54.7%
32.6 – 62.4
36.8 – 71.5
41.9%
41.6%
33.1 – 51.2
29.3 – 54.9
Figure 15: Sources of information (%) among respondents with BCC exposure
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
Figure 16: Frequency (%) of specific message recall if BCC exposure
From the series of questions on the respondent’s confidence to take action to protect the family with nets
an “action score” was constructed (details see methods) and households were categorized as “very
confident” which is equivalent to responding to all questions with agreement or strong agreement. When
the source of nets of households that had been aware of the CDD distribution was compared between
those “very confident” and those “less confident” it showed that for the ANC channel and nets from family
or the commercial sector the difference between these groups was relatively small (Figure 17). But for the
CDD and health facility channels very confident households were five times as likely to have obtained a
new net through these channels. It is, however, not clear from the data whether they got the nets through
these channels because they were confident or whether they were confident because they had gotten
the nets.
Figure 17: Access to new ITN from different channels among households aware of CDD program by action
score (less confident=<1.5, very confident ≥1.5)
Net use
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
The proportion of the de-facto population that used an ITN the night before the survey decreased from
32% at baseline to 8.9% at endline but in 2014 the use rate was significantly higher in the CDD distribution
are compared to non-CDD distribution with 17% vs, 5%. There are two main reasons for this decline, first,
the lower ITN ownership and access (see Table 3) and the fact that the endline survey was done at the
end of the dry season when use tends to be lowest compared to the baseline which was done at the end
of the rains (see Figure 5). As shown in Table 6, the seasonal use pattern resulted in a lower proportion of
those that could have used an ITN (access) actually using it. In other words the behavior linked “use gap”
increased from 39.3% at baseline to 59.5% at endline, but was somewhat lower in the CDD distribution
area (50.6% vs. 69.4%) even though the difference did not quite reach statistical significance (p=0.13).
Table 6: ITN use last night and ITN use if access to ITN
Indicator
Used an ITN last night
Used ITN if access
Baseline (Oct 2011)
Estimate
32.0%
70.7%
95% CI
27.7 – 36.6
65.8 – 75.2
Endline (April 2014)
Aware of CDD
Not aware of CDD
Estimate
95% CI
Estimate
95% CI
17.2%
10.3 – 27.3
4.8%
2.8 – 8.1
49.4%
30.6 – 68.4
30.6%
19.7 – 44.3
An analysis of ITN use by age group is presented in Figure 18 looking only at households with enough ITN
for all members, so that behavioral aspects of use are not obscured by lack of ownership. This
demonstrates that in general ITN use at baseline, i.e. at the end of the rains, was quite evenly distributed
between age groups and that especially the older children and adolescents who usually exhibit a lower
use rates did quite well. In contrast, at endline, i.e. at the end of the dry season, ITN use was much lower
at all ages except for the under-fives which even in the dry season showed ITN use rates close to what
had been seen in the rainy season.
Figure 18: ITN use by age group among households with enough ITN for all members
Finally, the source of the nets used by different age groups was explored to see which age groups used
which nets and results are presented in Figure 19. The first finding is that nets from ANC services were
primarily used by children under five and older children age 10-19 years, while CDD nets seem to have
filled the gaps for the rest of this age group and for adults age 40-59. Children under 10 and adults 20-39
were predominantly covered by campaign nets and people above 60 years of age almost exclusively used
nets from the campaign. Due to the small number of actual users it was not possible to also disaggregate
by gender.
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
Figure 19: Sources of ITN used by net users at endline survey by age
26
EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
Discussion
The primary purpose of this pilot community-based distribution of LLIN in Nasarawa State, Nigeria, was
to show proof of principle for a functioning push-pull continuous distribution channel. In evaluating the
outcomes one first has to consider the context of implementation of the pilot which included a number
of factors that did not favor positive results:
 The implementation of the pilot was delayed by several months and did not start until June 2013,
31 months after the mass distribution of LLIN. This only left ten months of implementation until
the endline survey which was driven by the end of funding for the project.
 Even during the implementation phase there were several stock-outs of LLIN from the central
system as well as repeated stock-outs of the net coupons
 During 2014 there were civil disturbances in many parts of Nasarawa State due to ethnic conflicts
which made communication with some areas difficult
The basic design of the evaluation was a before-after comparison using a state-representative sampling
approach equivalent to what is used in a DHS or MIS. Embedded in this design was an intervention-control
comparison at endline between areas (Wards) earmarked for CDD distribution and those not. However,
during the analysis it was found that no difference was seen between these two groups in awareness of
CDD distribution, receiving new LLIN from CDD or any other major outcome. This implied that there had
not been as strict a separation of these areas as anticipated, or that changes were made after the
evaluation was designed. The analysis then used the actual awareness of households of the CDD
distribution scheme as criterion for within endline survey comparison which can be seen as a “per
protocol” analysis that still provides strong evidence, but not quite as strong as an “intention to treat”
analysis would have provided.
The first major finding of the evaluation is the generally low awareness of the CDD scheme with only 32%
of respondents recalling that the CDD scheme had been announced in their community, and that only
13% of the 60 surveyed communities had more than half of the sampled households aware of the CDD
distribution. Although one has to consider that some respondents may have forgotten having heard the
announcement 10 months earlier, these results strongly suggest that the communication about the
scheme was not sufficient.
Program effectiveness, i.e. the steps from knowing about the scheme and actually getting a new LLIN was
poor with only 18% of those knowing about the scheme actually obtaining a net. The biggest loss in
effectiveness came from a very low rate of actually requesting new nets from the CDD (35%). This was not
because people already had enough nets as this was mentioned by only 1.2% of respondents as the reason
for not requesting if they knew about the distribution. The major reasons were logistical with either nets
or coupons being not available (55%) or people not being clear how the scheme worked (42%). Once
households had requested new nets, program effectiveness was significantly better with 51%, and here
losses came again from unavailability of nets or coupons, or stores being closed when people came. The
best effectiveness was seen between getting a coupon to going to the distribution point to redeem it
which was 93% showing that people that understood the scheme also utilized it well. The program
effectiveness in Nasarawa was generally lower due to the logistic and information deficits than had been
seen in two other, similar community-based distributions which have been implemented by the NetWorks
project in Southern Sudan and Madagascar which had a request to receiving LLIN effectiveness of 93%
and 80% respectively.
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
Considering the limitations outlined above, the impact of the CDD distribution on the ITN ownership
indicators in the “per protocol” analysis were quite impressive as they were twice as high as in households
without CDD distribution: 55% vs. 28% for any ITN ownership, 17% vs. 6% for at least one ITN for every
two people in the household (enough ITN), and 35% vs. 16% for population access to ITN within the
household. The rates among households aware of the CDD distribution were still lower than in the
baseline survey 11 months after the campaign, but this is hardly surprising as the projections with the
NetCALC tool (see Figure 2) were done assuming start of the continuous distribution within the first year
after the campaign. Since this did not happen until more than two years after the campaign and a
significant proportion of the population was not even aware of the CDD scheme, the LLIN distributed could
not be expected to reach again the post-campaign level.
The data show, however, that the community-based distribution significantly improved the ITN coverage
situation and did so without oversupplying those households it did reach and nicely complemented other
LLIN distribution channels such as ANC, commercial sector and nets obtained from family or friends as
there was very little overlap (see Figures 10 and 11). Furthermore, even though the distribution was not
perfectly equitable as was the campaign distribution, the pro-rich inequality was not very pronounced
with concentration indices not exceeding 0.15 whereas significant pro-rich inequality often is found to
show indices of 0.3 or even 0.5. The major reason for the inequality could be identified as poorer
households being less likely to request a new LLIN even when they knew about the CDD distribution and
this issue can be addressed through BCC.
Given that the endline survey had to be conducted at the end of the dry season rather than at the end of
the rains for funding reasons, it was not surprising to find a significantly lower use rate for people who
had access to an ITN compared to the baseline survey which had been done at the end of the rains.
Nonetheless, the use gap in households that participated in the CDD distributions and had consequently
been exposed more often to ITN related messages was significantly lower compared to households not
aware of the CDD scheme: of those that could have used an ITN 51% did NOT do so in the CDD group
compared to 69% in the non-CDC group. This shows that the BCC linked to the community-based
distribution was very effective to enhance net-use related behaviors, even though it had been insufficient
to reach enough households with the knowledge and understanding about the CDD scheme.
Conclusion and Recommendations
The evaluation of this community-based distribution scheme showed that
 A community-based push-pull distribution system can work well to reach households missed by
the campaign, those who did not get enough nets or have lost the ones they had provided the
scheme is well advertised and the logistics of supply function smoothly
 These distributions do not oversupply households but help to supply just enough for all members
to use ITN
 There was very little overlap with other supply channels showing that these distributions
complement each other in reaching all households
 Community-based distribution in this setting is reasonably equitable and equity can be further
improved if the poorest wealth quintile is encouraged to request new nets
 BCC linked to the community-based distribution is an important contributor to enhance messages
on ITN use resulting in better utilization by those with access
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EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
The following major recommendations can be made:
 Community-based distributions – like all other continuous channels – need to be started at least
within one year following a successful mass LLIN campaign which implies that preparations should
always start even before the campaign takes place
 Informing the population about the distribution scheme and carefully explaining how it works is
critical and must be emphasized during roll-out as this will a the most important step to achieve
high program effectiveness
 Special attention should be paid to involving the poorest households to ensure that they feel
encouraged to participate in the scheme
 Logistics systems need to function smoothly and all efforts should be made to avoid stock-outs of
LLIN and net coupons
 BCC messages supporting use of nets should always be incorporated in such distributions
29
EVALUATION OF COMMUNITY LLIN DISTRIBUTION, NIGERIA
30