Lessons learned from bednet distribution in Central Mozambique

Introduction Malaria is an important cause of mortality and morbidity in sub-Saharan Africa. Use of insecticide-treated bednets (ITNs) is an important preventive intervention. Selection of the best mechanisms for distribution and promotion of ITNs to vulnerable populations is an important strategic issue. Methods Commercial shopkeepers and groups of community leaders were trained to promote and sell ITNs in 19 sites in central Mozambique between 2000 and 2004. Pregnant women and children under 5 years of age comprised the target population. Sales records, household survey results and project experiences were examined to derive 'lessons learned'. Results Primary outcome: An end-of-project household survey revealed that 40.8% of households owned one or more bednets, but only 19.6% of households owned a net that had been re-treated with insecticide within the preceding 6 months. Higher levels of bednet (treated or untreated) coverage (over 50%) were achieved in urban or peri-urban sites than in rural sites (as low as 15%). Bednet ownership was significantly associated with higher socio-economic status (odds ratios for association with bednet ownership: 5.6 for highest educational level compared with no education, 0.4 for dirt floor compared with cement or other finished flooring, 2.1 for automobile ownership compared with transportation on foot), but was negatively associated with the presence of young children in the household (odds ratio 0.5). Primary output: 23 000 ITNs were sold during the course of the project. Process lessons: Nearly all of the community leader sites failed and were replaced by shopkeepers or Ministry of Health personnel. Sales were most brisk in more prosperous urban and peri-urban sites (up to 147 nets/month) but were significantly slower in poorer, rural sites (as low as three nets/month). Remote rural sites with slow sales were more expensive to serve. Logistical difficulties were related to tariffs, transport, management of cash, warehousing and organization of re-treatment campaigns. Conclusions This project failed to achieve adequate or equitable levels of ITN coverage in a timely manner in the programme sites. However, its findings helped support a subsequent Mozambican decision to conduct targeted distribution of long-lasting nets to the neediest populations in the provinces where the project was conducted.