Community-Based Distribution: Pulling It Off in South Sudan

This 5-page brief shares information about a programme in South Sudan that is designed to encourage families to request for long-lasting insecticidal nets (LLINs) when they need them, even after distribution campaigns are complete. While many campaigns focus on "pushing" the distribution and use of bed nets, this is a "pull" system designed to respond to ongoing family needs. Funded by the United States Agency for International Development/ President’s Malaria Initiative and the Department for International Development, this programme focused on creating a community-based continuous distribution channel with the use of coupons, which are distributed by a designated person in the community to families that request them. They can then be redeemed for a net at a primary health care facility. As stated in the brief, "monitoring data from the first six months of the pilot shows that community acceptance is high and redemption rates are at 84 percent. Much of this success has been attributed to behaviour change communication, close supervision, flexibility, and strong partnerships."

According to the brief, this community-based distribution approach was developed because distribution through mass campaigns and routine health services was limited and that even where coverage is reached, "it begins to decline immediately after campaigns due to wear, tear, and loss." Routine distribution through public health facilities was especially limited because of low service utilisation, in particular by women and children. In addition, the post conflict setting in South Sudan meant that distribution to families was a challenge.

In order to create the "pull" in the system, the programme involved social mobilisers, clergymen, and health facility staff who sensitise households about the importance of using nets and the process for obtaining and redeeming net coupons. People with a damaged net, more than two people sleeping under one net, or recent mothers who did not receive a net during antenatal care (ANC) are eligible to receive a coupon. Household members approach a Net Coupon Holder (NCH) in their community. If eligible they receive a coupon, which they redeem at the nearest Primary Health Care Center or Unit (PHCC/U). In order to monitor the distribution of coupons, NCH Supervisors randomly select 50-60 recipient households monthly, to check that the coupons are being issued to eligible families and that nets are being hung correctly.

As part of the project, training was conducted using a cascade model - the project coordinator and project officer trained twelve staff from the County Health Department, who in turn trained volunteers. The volunteers receive "a two-day training on the pilot's design, malaria prevention, behaviour change communication, and monitoring. They were also trained on the data collection tools and information, education, and communication materials. Assistant Store Keepers were trained on-site after the distribution began. Laminated job aids and refresher trainings were provided after supervision visits identified inconsistencies in implementation."

During the preparation phase of the project, focus groups helped to develop the communication strategy. The key messages identified and promoted through volunteers are to "inform communities about the pilot, the criteria for eligibility, and when and where to obtain and redeem coupons. They also inform them about the usefulness of nets in preventing malaria, sleeping comfortably, and keeping harmful pests out of bed." The same messages are also promoted by social mobilisers through megaphones at community gatherings and markets, and by church leaders during services.

The case study identifies the following lessons learned, as extracted from the brief:

• "Understand the context and have the flexibility to adjust to the changing environment.
• Constant engagement with stakeholders is crucial. Communities appear to dislike targeted distributions because they limit many members’ access to nets. Support for the pilot was higher when eligibility was based on household need and not pregnancy status or age.
• Increasing geographic access may be more important than increasing operational hours in this setting. Conveniently-located facilities with secure “dropboxes” and limited hours have redemption rates that are as high as, or higher than, facilities that redeem nets every day.
• Significant but measured logistical support is essential. Consistent logistical support can help prevent stock-outs of nets and other project supplies. But it is also important to minimise the costs and security risks associated with frequently transporting nets. One way to do so may be to increase storage capacity at redemption sites while maintaining strong supervision of the restocking process.
• Community demand will drive the frequency of restocking visits. Demand may vary as a result of communication and seasonality. It may also stabilise over time.
• Avoid overloading busy workers such as health facility in-charges and community leaders by assigning net coupon and redemption responsibilities to ancillary staff and other respected community members. This can reduce the potential for long wait times and avoid interfering with service provision. In-charges and community leaders can maintain a small but key role through overall facility or community supervision.
• Communication about the value and use of LLINs can help motivate households to take the time and effort to seek coupons and travel to facilities. Redemption rates can be high even when some effort on the part of communities is required.
• Support supervision is essential for the volunteers and county health department to strengthen their capacity to implement the pilot."

Click here to download the full report in PDF format in French.

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