CHALLENGES OF LLIN
DISTRIBUTION IN PAPUA
• Historically Papua New Guinea
has one of the highest burdens
of malaria outside of Africa.
• PNG has annually been
reporting about 1.7 million
cases plus about 600 deaths.
Annual incidence rates have
been about 300 per thousand
• One of the first globally
published works on the efficacy
of treated nets was carried out
by IMR (Institute of Medical
Research) in PNG.
• PNG has therefore long
experience with treated
mosquito nets since about
1990 from which time nets
were distributed around
PNG by projects and
• Rotarians Against Malaria
started in 1997 by Port
Moresby Rotary Club to
supply treated nets to
private and NGO sector.
• Massive scale up of nets started with Round Three
Global Fund Grant (2005 to 2009) coordinated by
the National Department Of Health (NDOH)
covering about 80% of the population. During this
phase about 2.5 million nets were procured.
• Nets delivered at rate of one net to every two and a
half people with different sizes of nets supplied.
• Distribution done well in many places but also done
badly in many other places and some places left
• Problems include not following national guidelines,
poor reconciliation of money and few good reports
submitted to central level.
• Biggest problem faced was timely transfer of funds
from Central to Provincial Level.
• Further scale up of LLINs occurred with Round
Eight Global Fund Grant from 2010 to 2014.
• Rotarians Against Malaria given the mandate to
coordinate the distribution of nets to all villages in
Papua New Guinea in collaboration with the
National Department of Health (NDOH).
• RAM responsible for procurement, planning and
finance while implementation is carried out jointly
with provincial health authorities and small teams
of RAM field officers.
Of Nets In
• To date RAM has coordinated the distribution of 4.3
million nets to household level.
• RAM covered 84 out of 90 districts and 19 out of 20
provinces with last province being covered now. A
further 23 districts covered for a second time after
three year interval.
• Has reached about 21,600 villages with only 15
villages in areas covered not reached due to a
number of reasons including tribal fights at time of
distribution. These areas will be covered in 2014.
• 620,000 LLINs also distributed to antenatal women
(80%), boarding schools and prisons.
• Impact on malaria has been
• Clinical malaria incidence has
fallen by as much as 70%
following a distribution by nets
in a district.
• Prevalence of malaria has
fallen by 75% in some regions.
• Reduction mainly attributed to
LLINs even though RDTs and
ACTs now in all Health
Centres in the country.
• People have been generally
very happy with the
• PNG has very poor
• Generally very wet climate
causing almost impassable
roads and landslides.
• Mainland PNG has about six
separate road systems that
do not connect.
• In general these roads are
• In most parts of the country
there is no clear dry season
so no clear time frame to
carry out operations.
• Many villages may take
several days to reach by
combinations of road, air
boat and trekking.
• Low education levels.
• Tribal fights.
• Health staff not knowing
their own areas.
• Fraud, conflict of interest
and other types of
• Drunkenness and traffic
• Weak government
institutions and very poor
• Weak, expensive and
• Poor banking coverage.
• Donor restrictions.
• Have reached almost all the
remotest communities in the
• Project returns to villages
missed out initially.
• All results are presented to
• RAM has brought quick transfer
of funds to the programme and
a consistent methodology in
terms of implementation and
consistent financial and
• Almost no leakage of nets to
• Has achieved very good
communities and health
authorities who have now
requested that RAM
continue with the
programme in the future if
• Mapped out elephantiasis
and now cell phone and
radio coverage at village
• Anecdotal evidence says
that more children go to
MOAs And Coordination
• MOA were signed with all
Provincial Administrators though
one province never signed.
• The programme is introduced to
Provincial Health Advisors and
health team in each province and
together a budget and all the
logistics to carry out the
programme is worked out.
• Throughout the project RAM works
in close coordination with
respective provincial and district
• A village list is made of each district
based on the 2000 census. Information
includes projected population for each
• Unit of implementation is health
• District health staff are asked to
allocate each village to a health centre.
• This is the basis of planning in terms of
nets needed and how many teams are
needed to cover each area.
• Partners are identified who can help
with staff and logistics particularly in
places of difficult access so that every
village in a district is reached.
• Logistics are identified that are needed
to carry out the survey. Cars, boats,
helicopters, airplanes and number of
staff needed for how many days based
on two staff per team. For difficult to
reach places different alternative
budgets are considered using different
types of transport e.g. walking against
use of air planes or boats.
• Budgets are made for fuel, hiring
vehicles or boats if necessary and staff
costs. Volunteers are paid 20 Kina
(US$7) a day and MOH staff 30 Kina
(US$10) a day.
• RAM team members allocated to
work with specific health centres.
• RAM team members carry out micro-
planning exercise with health centre
• Micro-planning involves drawing
rough maps of the area and then
defining daily movements of teams to
cover all villages.
• Also budgets are verified at this point
and head office is alerted if mistakes
have been made with budget. This is
usually the result of bad information
given at planning stage.
• A programme of social mobilisation is
carried out to inform villagers of the
programme as well as passing on
basic health education messages
about malaria. RAM tries to use all
local organisations e.g. Ministry of
Health, Ministry of Education, Council
Meetings, NGOs, Church groups
CBOs etc. Social mobilisation activities
start a few days before the survey.
• During this time a one day training is
held with all people involved with
survey. This should involve surveying
one village together.
• Before starting the census process in
any village, a meeting is held with
village elders explaining the process.
• Where village is small, e.g. less than 30
families, teams members to carry out
• Where villages are large, village
volunteers are selected and trained to
carry out survey.
• Each family censured separately and
• Each family member is recorded by
name, age, sex and relationship to
head of household.
• Survey teams return within an agreed
period to pick up survey book e.g. two
to four days.
• One village volunteer is be chosen for each
of about 50 families. Where possible
volunteers should be chosen by natural
divisions in the village e.g. clans where one
volunteer would make a list of only one clan
• Surveys involve recording everyone in the
household who normally resides at the
household for more than nine months of the
year. Children in boarding schools are also
included as well as family member away at
the time of the survey who normally reside
in the village.
• Health education messages also given out.
• In all cases, after the census/list taking
is finished, the list of family members
should be read out to a meeting of
village people to verify that no one has
been included that should not be there
and that no one has been missed.
Village elders sign a form to verify that
this was done.
• All lists are reviewed and results of
each survey book written on the
outside of the survey book. Information
should include district, LLG, ward and
village name together with total
population of each village included in
• Before starting the distribution, it is necessary
to verify that data on all villages in the 2000
Census are collected.
• For each village, the populations surveyed
should be compared with projected population
of the 2000 Census.
• If population collected for each village is
very different from predicted population,
this is investigated.
• If population is similar to that predicted,
each family should be allocated nets
based on need and the total number
written on outside of survey book.
• Allocations of nets are verified in each
village to make sure that this has been
done correctly to ensure that there are
enough nets to reach every family
• Distribution is based on the needs
of a family.
• One net for mother and father
and up to two children under
the age of six.
• One net is given to boys
between the age of 6 and 16
(one net for three boys)
• One net is given to girls
between the age of 6 and 16
(one nets for three girls).
• Extra nets are given for other
• All nets opened prior to
distribution and marked with
provincial code and year with a
• Only a family member from
each family can receive nets
on production of a white
• If white receipt is lost then
person waits to end of
distribution to find their names
in the survey books.
• If certain families are not
present, these nets are handed
over to the village elders using
a trust form in front of villagers
so that there are witnesses.
Village elders must sign for
• At the end of the distribution,
all volunteers are paid and a
report made which includes
problems found as well as
positive aspects of the
ADVANTAGES OF THE
• One organization coordinating a country
ensures consistent type and quality of
implementation and reports on financial and
• Sequential mass distribution as opposed to
one off mass campaigns ensures expertise is
not lost between campaigns and allows for
greater quality assurance and detailed
• Allow health system to do what they are best
• Have had no serious
incidents where staff have
been seriously injured or
died despite difficult
conditions. Minor accidents
include air crash, boats
capsizing, tribal fights and
numerous small car
• Had no serious loss of
money in the field except
some officers who stole
funds and another officer
when his boat capsized.