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TABLE OF CONTENTS
DECLARATION……………………………………………………………………………………………. ii
DEDICATION………………………………………………………………………………………………. iii
ACKNOWLEDGEMENT………………………………………………………………………………. iv
TABLE OF CONTENTS…………………………………………………………………………………. v
LIST OF TABLES………………………………………………………………………………………… vii
LIST OF FIGURES……………………………………………………………………………………… viii
ABBREVIATION…………………………………………………………………………………………. ix
OPERATIONAL DEFINATION OF TERMS…………………………………………………… x
ABSTRACT………………………………………………………………………………………………….. xi
CHAPTER ONE:INTRODUCTION………………………………………………………………… 1
CHAPTER TWO:LITERATURE REVIEW………………………………………………………. 8
CHAPTER THREE: MATERIALS AND METHODS……………………………………… 27
CHAPTER FOUR: RESULTS AND DISCUSSION………………………………………… 34
4.2.1 Effect of mass distribution strategy………………………………………………. 36
CHAPTER FIVE: DISCUSSION, CONCLUSION AND RECOMMENDATION. 57
REFERENCES……………………………………………………………………………………………… 63
MAP OF KENYA……………………………………………………………………………………… 69
MAP OF MAKUENI DISTRICT………………………………………………………………… 70
MAP FOR KWALE DISTRICT………………………………………………………………….. 71
KEY INFORMANT INTERVIEW SCHEDULE (Facility in-charges; District level managers) 72
Table 3.1 Breakdown of the Proportionate allocation of the calculated sample 30
Table 4.1 Breakdown of sampled population (cross sectional survey)……………. 34
Table 4.2 Bed net distribution strategies……………………………………………………. 43
Table 4.3 Reasons for selling subsidized nets to non targeted groups according to health facility in charges…………………………………………………………………………………….. 44
Table 4.4 Supplier related challenges to distribution……………………………………. 47
Table 4.5 Logistical related challenges to distribution…………………………………. 49
Table 4.6 Regulatory related challenges to distribution……………………………….. 50
Table 4.7 Factors affecting community access to the bed nets……………………… 52
Fig 1.1 Conceptual framework………………………………………………………………. 7
Fig 1.2 Global prevalence of Malaria………………………………………………………. 9
Fig 2.2 Prevalence of malaria in Kenya………………………………………………….. 13
Fig 4.1 Bar graph showing the level of education among the adults………….. 35
Fig 4.2 Bar graph illustrating the Change in household net ownership after the mass distribution 36
Fig 4.3 Bar graph comparing net usage among key vulnerable groups after the mass distribution 37
Fig 4.4 Bar graph showing sources of bed nets in the households…………….. 38
Fig 4.5 Bar graph showing the reasons for not owning a net at household level
……………………………………………………………………………………………….40
Fig 4.6 Bar graph comparing bed net ownership by socio-Economic status
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ACT Artemisinin-based Combined Therapy
AL Artemether Lumefantrine
AMREF African Medical Research Foundation
ANC Ante Natal Care
DOMC Division of Malaria Control
EPI Expanded Program for Immunization
GFTAM Global Fund to Fight Tuberculosis Aids and Malaria
GOK Government of Kenya
GSP Global Strategic Plan
HQS Headquarters
HIV/AIDS Human Immune Virus/Acquired Immune Deficiency Syndrome
HSSP Health Sector Strategic Plan
HH House Hold
IPT Intermittent Preventive Therapy
ITN Insecticide treated Net
LLITN Long Lasting Insecticide treated Net MDG Millennium Development Goals M&E Monitoring and Evaluation
MIM Multi Lateral Initiative on malaria
MOH Ministry Of Health
NMS National Malaria strategy
NGO Non Governmental Organization
PCA Principal Component Analysis
PEPFAR President’s Emergency Plan for AIDS Relief
PMI President’s Malaria Initiative PLWHA People Living With HIV/AIDS PSI Population service International
RBM Roll Back Malaria
SES Social Economic status
SSA Sub Saharan Africa
TB Tuberculosis
UNICEF United Nation Children’s Emergency Fund
WHO World Health organization
Adults: These are people who are above the age of 18 years. At this age a person is expected to have some degree of independence to be capable of making decisions
Bed net: This is any net used on the bed for protection against mosquito bites. It could be treated with a mosquito repellent or not.
Bed net distribution strategy: This is any method that is used to deliver the bed nets to the users.
Intermittent Preventive Treatment: this is a public health intervention aimed at treating and preventing malaria episodes.
Malaria Vulnerable groups: These shall consist of pregnant women and children aged below five years
Roll Back Malaria: Its a global framework for coordinated action against malaria it forges consensus among key actors in malaria control harmonises action and mobilises resources to fight malaria in endemic countries.
Subsidy: This is a benefit given by the government to groups or individuals to keep the price of a product (bed net) low.
Women of reproductive age:
These are women who are between the ages of 18 – 49 years. Women of this age bracket are considered to be more likely to become pregnant hence being vulnerable to malaria
Insecticide Treated Net (ITN):
This is a mosquito net that is pre treated with mosquito repellent. The treatment can last from six months to five years.
Malaria causes immeasurable human suffering in the tropics and the sub tropical areas. The disease is a leading cause for both mortality and morbidity with an estimated 300-600 million people being infected with malaria every year in the world. The World health Organization estimates that 90% of malaria deaths occur in Sub Saharan Africa. Insecticide Treated Nets (ITN) are a cost effective malaria control tool but coverage data has often showed that the majority of Sub Saharan countries are below the targets set by the Roll Back Malaria Initiative. While a lot of research has focused on the demand side perspectives of ITN uptake little has been done on the supply side factors affecting ITN coverage. This study establishes the distributor and user perspectives on ITN distribution strategies and whether they are reaching the poor and vulnerable to malaria. The study was descriptive cross sectional and was built on a larger study that explored access to malaria treatment and prevention among the poor. It was carried out in Kwale and Makueni Districts. Primary data arising from key informant interviews and semi structured interviews were used to gather the ITN distributor‘s perspectives. Secondary data arising from two cross sectional surveys carried out by the wider study gave the user perspectives of the bed net access. STATA version 9.2 was used to analyze the quantitative data while the qualitative data was analyzed using the thematic framework analysis. The study identified three main distribution strategies: free distribution (distributed through the mass campaign and routinely by Non Governmental Organizations), Social Marketed subsidized nets and commercial distribution of nets. All the distribution strategies deal with limitations that could be supplier related, logistical, market related or organizational. The majority of retail outlets had stopped selling bed nets and retail owners described the bed nets as a very slow moving product. Slightly over a half of the respondents in Makueni and just above a quarter of the respondents in Kwale said they could afford to purchase a bed net (76 (54%0 Makueni and 31 (17%) in Kwale). The free mass distribution was shown to have resulted in significant increase in bed net ownership in the two districts (from 88 (48%) to 124 (74%) in Kwale and from 76 (54%) to 102 (82%) in Makueni). In Kwale District people belonging to the high Social Economic Status (SES) were more likely to have benefited from the mass distribution exercise. In Makueni district, there was no association between a household’s likelihood of owning a bed net and its SES. Acceptability of bed nets was high in the communities studied. Statistical tests on the findings revealed that acceptability was related to bed net ownership. This study concludes that the mass distribution reaches the majority in a community and the strategy is effective at scaling up coverage in a short while. The commercial distribution strategy needs to be protected from collapse to ensure that bed nets are accessible and available throughout the year. Methods of ensuring that the poorest of the poor within the target groups are reached by all the strategies need to be explored to ensure that the poor benefit from the public health resources. Stringent monitoring and evaluation systems for existing distribution strategies need to be instituted to ensure early identification of bottlenecks, lesson learnt and correction for success of the program.
Malaria is considered the most important infectious diseases in the world killing approximately one to three million people each year. Worldwide some 300 to 600 million people are infected with malaria each year (Snow et al., 2005). The World Health Organization (WHO) estimates that of all the malaria deaths 90% occur in Sub-Saharan Africa (SSA). Malaria is both curable and preventable yet a large number of deaths and attacks of the disease are experienced especially in Africa (Meek et al., 2005).
Typically pregnant women and children aged below five years are considered vulnerable to the disease because of biological factors that weaken immunity making any attack life threatening (WHO, 2000). Similarly a poor person is vulnerable to the disease because they are less likely to afford measures to protect themselves or deal with the consequence of disease should it attack (Bates et al., 2004).
Insecticide Treated Nets (ITNs) have been identified to be a cost effective method of reducing malaria related morbidity and mortality (Heidi, 2006). They provide significant protection against early childhood mortality under a range of malarial settings and because of these, countries and the international community are advocating for ITN uptake among the malaria endemic regions (Lengeler, 2007).
Malaria is undoubtedly a world problem and it has elicited response from the international community. Various initiatives like the Roll Back Malaria (RBM), Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM), the Multilateral
Initiative on Malaria (MIM) and United Nations Children’s Fund (UNICEF) are working in partnership to reduce the burden of malaria. Common across all the initiatives is the recognition that ITNs form an integral part in malaria control.
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