Nothing but Net(s): Distributing Insecticide-Treated Nets at Scale in Togo

By Caitlin Gruer
August 30, 2016

Insecticide-treated bed nets are proven to prevent malaria-related morbidity and mortality.

In addition to directly protecting those who use nets, there is evidence that they also act as protectors for the community at large. Because of this, insecticide-treated nets – or “ITNs” – play a critical role in the fight against the disease. 

Different countries utilize varying strategies to deliver ITNs at scale. The most common include: continuous delivery of partially subsidized ITNs through the health sector and private sector; continuous delivery of free ITNs at antenatal care clinics; one time distribution of free ITNs during a standalone ITN campaign; and one-time distribution of free ITNs during integrated health campaigns.  Most of these strategies target children under the age of 5 and/or pregnant women as these populations face the greatest risks of malaria.  While each strategy has its pros and cons, the World Health Organization (WHO) found that, in general, time-limited delivery strategies were more equitable and pro-poor.

Togo is one of the countries that has implemented time-limited distribution campaigns for ITNs. In fact, Togo was the first country in Sub-Saharan Africa to implement an integrated health campaign that included ITNs. 

In 2004, Togo began implementing integrated child campaigns, incorporating ITNs to combat the leading causes of childhood mortality.  However, the integrated campaigns in 2004 and 2008 only targeted children under the age of 5.  In 2011, the country began to implement integrated health campaigns that target universal ITN coverage at the national level. 

The 2011 campaign incorporated mass drug administration against three neglected tropical diseases: onchocerciassis, schistosomiasis, and soil-transmitted helmithiasis, which are all variations of parasitic worms. The campaign included administration of Vitamin A and three anti-parasitic drugs. 

The final component of the campaign was ITN distribution.

This is where Plan International stepped in.

With support from the Global Fund, Plan worked with the government of Togo and other partners to organize ITN distribution.  The campaign aimed to achieve universal ITN coverage, which is defined as one ITN for every 1.8 people.

Although the distribution was an overall success, the large-scale operation presented a number of challenges. To learn about these challenges, we talked with Thidiane Ndoye, who oversaw the project from the Plan office.*

Some of the key project challenges included:

  • Logistics:  Distributing bed nets to all households on a national level is a huge undertaking, and ensuring that the proper number of bed nets are procured, delivered, and distributed to the right locations takes careful planning. In Togo, the sheer number of bed posed a problem due to the size of the port.  The ships delivering the ITNs were delayed for weeks because they had to wait offshore until there was room to dock at the port. Similarly, once the ITNs were offloaded onto the trucks headed for the district warehouses, the vehicles had to wait days to be able to leave the port as a result of massive freight unloading congestion. 
  • Integration: Because the bed net distribution was one part of a larger integrated health campaign led by the government of Togo, there were many stakeholders involved in the process.  Plan had to work closely with the Ministry of Health, a network of community health workers, the private sector, and other partners to implement this initiative.  While this broad buy-in and involvement allows for a successful, comprehensive campaign, the transaction costs associated with building a multi-stakeholder delivery system are high and necessitate strong coordination and aligned incentives.
  • Ownership: Plan implemented this distribution through, and with, existing in-country structures.  While Plan oversaw the process—including inventorying and shipping the ITNs and training stakeholders— local partners (including the health facility staff, MoH staff, and community health workers) were responsible for the actual distribution.  This strategy not only provided the necessary manpower for large scale implementation, but also ensured local ownership in the process.  However, despite these benefits, the approach did pose some challenges. 

As Thidiane noted: “At some point, you lose control of the operations, and when you lose control there is a point where you depend on people, health providers and all that. Sometimes they don’t see that activity as their own. They see it as Plan’s activities.” To combat this, Plan works closely with local stakeholders to build buy-in and ensure local ownership. 

Despite these challenges, the 2011 ITN distribution was tremendously successful.  Plan distributed 2,799,800 bed nets throughout Togo, which accounted for 99.1 percent of eligible households. The model was so successful, in fact, that the government of Togo, the Global Fund, and Plan partnered again in 2014 to implement a similar distribution. 

*Although Thidiane Ndoye was a Plan employee at the time of the conversation, he no longer works with the organization.