Context
Benin's population is estimated at 12,114,193 inhabitants in 2020 [13]. The country is divided into 77 communes grouped into 34 health zones and 12 departments (Fig. 1). Malaria is endemic in all parts of country with seasonal variations. All of Benin’s population is at risk of malaria infection, which is the leading cause of morbidity and mortality. The incidence of the disease in 2018 was 18.5% in the general population with 1,755,597 confirmed cases of malaria in public health facilities and almost 2,251 deaths due to malaria, most of which are in children under five years [14].
As far as the evolution of the COVID-19 pandemic is concerned, Benin recorded its first official case on March 19, 2020 after the enumeration phase. On the eve of the distribution phase, there were 26 official cases with one death. Just after the distribution phase, 64 cases and one death were officially reported. As of November 05, 2020, there are a total of 2781 cases and 43 deaths.
Digital aspect of the ITNs mass campaign
Catholic Relief Services (CRS) gave support to the Government of Benin and the NMCP in digitizing the 2020 ITNs mass campaign. CRS commenced its work with planning and capacity building sessions with NMCP staff. There was training of campaign staff on the use of digital tools and over 27,000 participants at these sessions were digitally-tracked using their biometrics as a mean of validating their attendance to each training session. The digital platform is the Cash-and-Asset Transfer Platform (CAT). A total of 3,382 smartphones and 350 solar chargers were used to perform a household enumeration to register households within the country to obtain a robust population database. It consists during the enumeration phase to collect using smartphones, household information (size, name, gender and age of household members), and then a coupon was assigned to the head of household with a unique Quick Response (QR) Code. The same digital platform was used to track distribution of ITNs and verify that all households registered received the correct number of ITNs allocated to them. The data collected on CAT was available through an online dashboard, updated in real time, allowing field supervisors to make important decisions effectively, and efficiently tracking household coverage rates as households missed were identified using sequencing and geospatial analytical dashboards easily accessible for field supervisors.
ITNs campaign implementation process
Fig. 2 shows the different sections and the implementation process of ITNs mass distribution campaign.
Macro-planning
Macro-planning consisted in quantifying the number of ITNs required to achieve universal coverage according to the 2020 population projection data. In addition, the strategies for the household enumeration as well as for the ITNs distribution were designed.
Drafting of the campaign protocol
After the macro, the protocol of the campaign was written in great detail. This protocol was then validated by all stakeholders and consisted henceforth the campaign roadmap.
Micro-planning
A comprehensive micro-plan for the 2020 mass distribution was developed, which contains a rigorous gap analysis and the procurement plans as well as all details on campaign processes and a roadmap. The roles and responsibilities of actors at different levels of the health pyramid (central, department, health zone (HZ), and commune) have been clearly described.
Procurement and supply
A total of 8,609,873 ITNs were procured for this campaign for the whole country. All the ITNs used for the distribution campaign were manufactured in Asia (China and Vietnam). These ITNs were acquired by the government of Benin with the support of financial partners, including the Global Fund, the Bill & Melinda Gates Foundation and the United States Agency for International Development (USAID) through the President Malaria Initiative (PMI). ITNs were received in-country (without passing through central storage) and transported as planned from central level to department level and then to sub-division level. From there, they were transported to village level storage.
At the department warehouses, quality assurance was conducted prior to distribution. Samples of ITNs from different batches were sent to Centre de Recherche Entomologique de Cotonou, for physical and chemical analyses, such as stress analysis, insecticide content, fabric weight, netting, mesh size. A total of 837 ITNs were tested. All the samples conformed to the WHO procurement and use of ITN for malaria control requirements. Two days before the distribution phase, net were convoyed to each village leader.
Training
In order to create equal understanding among actors at different levels of the health pyramid on the campaign implementation strategies, training was organized in a cascade manner at central, department and district levels [15]. In each department, separate micro-planning workshops and training of trainers (ToT) sessions on implementation took place to train the health zone and district coordination groups. Significant adaptations were required for the training of the distribution supervisors and teams in light of the COVID-19 pandemic and the urgency to get ITNs into households through the revised distribution strategy.
Therefore, the following precautions have been taken:
- Training was adapted to take place over three hours with a maximum of 18 people per class
- Hygiene and safety measures were put in place (hand washing facilities, physical distancing, scanning of trainees’ badges rather than fingerprinting, health check).
- Rooms were cleaned thoroughly before and after every session
- Content for the shortened training sessions was revised to include door-to-door distribution techniques, with the use of smartphones, and hygiene measures emphasizing the importance of keeping at least one metre physical distance from any other person.
- Audiovisual files and the electronic version of the distribution guide were shared with the distributors at the end of the training to enable them to review the content of the training once at home
- Whatsapp groups have been created between trainers and distributors to facilitate exchanges after training.
Households enumeration
Household enumeration was conducted by volunteers who had at least a grade 7 at secondary school. Each enumerator team was made up of two people. The first person was equipped with a smartphone to record the household’s informations. The second person delivered to the household a voucher for ITNs in the form of coupon with a Quick Response (QR) code (Fig. 3), which is the unique identifier of the household. The coupon is then later exchanged for the corresponding number of ITNs in the distribution phase during which, the coupon once scanned, generates all the household informations and displays the accurate number of nets to be redeemed, based on the applied distribution key (1-2 persons = 1 ITN; 3-4 persons = 2 ITNs; 5-6 persons = 3 ITNs; ……..19-20 persons= 10 and more than 20 persons = 10 ITNs). The enumerator teams finally delivered key messages on malaria and the importance of sleeping under a ITN. The teams then progressed from house to house so as to cover all the households in the geographical area assigned to them, and had to register 60 households in rural areas against 70 in urban areas per day over a period of 16 days.
Mass distribution
The campaign was spread out in two phases. As it was the first time that Benin implemented a digital ITNs campaign, a pilot phase at the scale of a health zone was organized as a prelude to the national phase in order to understand the difficulties and constraints related to the use of digital tools.
- Pilot phase: Fixed distribution strategy
The initial approach was a fixed distribution strategy. During the pilot phase, which has implemented in one health zone (Abomey-Calavi/Sô-Ava) in the Atlantic department, ITNs distribution was done at fixed sites at the village level at a public place chosen for this purpose. Each household presented their coupon in exchange for ITNs. The number of ITNs to be allocated per household was displayed by the smartphone once the coupon has been scanned. The distribution teams involved in the distribution phase (planned for 4 continuous days, with 2 days extra) were composed of four fixed agents (Fig. 4)
- National Phase: Door‑to‑door distribution
During the nationwide phase, between the enumeration phase and the distribution phase, the COVID-19 outbreak occurred. Fixed distribution approach was not suited to this context. It became, therefore, necessary to revise the distribution approach. Thus, the distribution protocol was revised into a door-to-door distribution approach. By this approach, a distribution team directly delivered ITNs to recipients at their homes. The number of distribution team members remained the same, however their roles have been revised to adapt to the new distribution approach (Fig. 5).
Monitoring of household enumeration coverage
External monitoring was carried out by an external firm during the household enumeration. A rapid monitoring was carried out using Lot Quality Assurance Sampling (LQAS).
All of 77 communes were monitored. Monitoring results were shared at time with the actors and supervisors, in order to return to complete enumeration in low coverage areas.
Supervision and coordination
At the national monitor and district supervisor levels, planned field-based activities were reduced in scale. A daily scrutiny of the distribution data uploaded from the smartphones and a virtual meeting each evening allowed supervisors and monitors to focus on problem areas and challenges that could then be addressed and resolved. At the local level, supervisors focused on ensuring that distribution teams adhered to the covid-19 safety measures, as well as ensuring planning and management of the daily team movement plans. Their responsibility included checking the health of distribution team members each day and not allowing them to continue if they showed any covid-19-like symptoms. As yet, results of the local supervision have not been thoroughly analyzed, although anecdotally, it seems that it was quite a challenge for distribution teams to adhere closely to the distancing regulations. In addition, a whatsapp group has been created at the national level, which integrates the actors at different levels in order to resolve the difficulties and situations during the distribution.
Communication
The plan for communication included radio and television slots, town announcers and advocacy at every level. Advocacy meetings were completed in advance of the household registration phase, engaging leaders for the entirety of the campaign process. In advance of implementation of the revised strategy, messages were modified slightly to inform about the change of strategy, the new dates and the measures being taken to prevent transmission of COVID-19. As well as radio, television and town announcers, mobile messaging and audio call messages (for the less literate) were used. Community leaders were involved in local mobilization and were asked to be alert to any miscommunication that they heard about ITNs or COVID-19, and to report these to the community supervisor. Following the distribution, communication reinforced the messages passed to households by the distribution teams, i.e. proper airing of new ITNs, use of ITNs, hanging techniques and measures to prevent COVID-19.