Linking ITN Vouchers to Measles Immunization in Zambia: The Kalulushi Measles Campaign

Summary
In Zambia, the International Federation of the Red Cross (IFRC) and National Malaria Control Center (NMCC) asked NetMark to test the application of its successful discount voucher model in the context of the national measles campaign that sought to vaccinate all children under 15 from June 7-13, 2003. NetMark provided vouchers through the immunization clinics to children under five who received the measles vaccination while NetMark’s commercial partners procured and stocked ITNs in commercial outlets near the immunization sites. Following vaccination, parents in Kalulushi District received a voucher for each child under five and were able to redeem them for an ITN at one of the commercial outlets. Of the 14,895 vouchers distributed, 14,792 were redeemed-- a 99.3% rate. The cost per ITNs distributed was $4.88 with the commercial sector handling the procurement and distribution of the ITNs while the public health authorities handed out the vouchers, counseled parents, and carried out immunizations.


Background
NetMark had designed and implemented two pilot programs in Zambia that provided discount ITN vouchers to pregnant women attending antenatal clinics. Vouchers worth a K10,000 discount ($2.20) were given to pregnant women after malaria counseling at the clinics, and women were able to redeem the vouchers at multiple retail outlets and purchase an ITN of any size, shape, color, or price. The vouchers provided the public health system with a simple way of providing a subsidy directly to a high risk group while having the
commercial sector handle the complicated task of procuring, storing, distributing and selling ITNs and also redeeming the vouchers from retailers. Thus, it served to focus the public funding on the cost of the subsidy rather than the management and logistics and support rather than undermine the commercial sector. IFRC and NMCC wanted to see if this model could be applied to the national measles immunization campaign by providing a voucher for a 100% discount (i.e., a free ITN) to children under five who received the measles vaccination.

In several districts, the Red Cross, local health officials, Society for Family Health, and NGOs planned to distribute ITNs directly to the public at the immunization sites, taking on the task of ordering, storing, and distributing the ITNs themselves. The IDRC provided NetMark with funds for 15,000 ITNs. Kalulushi, a district in the Copperbelt with an under-five population of about 14,524, was selected as the site to test the voucher application. The commercial partners Cropserve, (distributors of FenNet and Fendona treatment kits) and EcoMed (distributors of K-ONet and the K-OTab treatment kits) performed well in getting the product to outlets within a short period of time and then redeeming the vouchers.

Planning Phase
The funding for this pilot was only confirmed a month before the campaign, so the entire program had to be put into place very quickly, including the importation of 15,000 ITNs, identification of outlets in Kalulushi, distribution of the ITNs to the outlets, and the design and printing of the vouchers and proof-of-purchase stickers for the ITNs. Because the commercial partners Cropserve and EcoMed had already participated in previous voucher programs, they were able to respond quickly to set up the entire logistics system.

Given the need for rapid action and the lack of time for the two commercial partners to follow their usual procurement process using Letters of Credit with net and insecticide suppliers, NetMark guaranteed payment to the net suppliers to facilitate the quick shipment of the ITNs. NetMark immediately reimbursed the two commercial partners for the CIF price of 7,500 ITNs each. All nets were double-sized conical nets, a highly popular size. The difference between the CIF price and regular retail price was paid to the commercial partners upon presentation of valid vouchers with proof-of-purchase stickers from the ITNs. This amount paid for the cost of warehousing, distribution, and redemption along with a modest profit. No extra fee was paid to the commercial firms for their participation in this activity.

As neither commercial partner had outlets and experience in Kalulushi, they sent their ITN managers to the district two weeks prior to the campaign launch to identify the immunization sites and retail outlets that were willing to stock ITNs and redeem the vouchers. Being a very poor area, there were not many outlets spread throughout the district to choose from. During their visit, it was discovered that some of the clinics were close enough to each other so that one retailer could service multiple clinics. Parents could pick up their child’s net with minimal inconvenience. For the Lukoshi clinic, the commercial partners had to place the ITNs in the clinic as there was not a single retail shop in the areas. The factors used to select the retailers were the size of the shop, security, and proximity.

Implementation Phase
The two commercial partners stocked ITNs in outlets near the clinics while NetMark printed the vouchers and job aids and briefed the government Malaria Agents who distributed the vouchers and provided advice on net treatment and ITN use. After immunization, the parent presented the child’s stamped immunization card to the Malaria Agent. The Agent confirmed that the child was the right age and issued a voucher for a free double conical ITN. The Agent explained how to treat an ITN and where the voucher could be redeemed. In many cases, parents did not have to walk more than 100 meters to redeem the voucher although the most remote area was 15 km. from the nearest ITN supply.

The first day of the campaign started off calmly. People lined up with their children to wait for their turn to be vaccinated; however, some disturbances soon occurred in the three main centers: Kalulushi Township Clinic, Kalulushi Government Clinic and Chibuluma Clinic when parents realized that the vouchers were not being given to children over five. People mistakenly believed that the ITNs were supposed to be issued to all who were being immunized. By midday, the situation was out-of-hand, and the crowd control people in each team could not handle the situation. Ultimately, the District Health Management Team called the police to come and restore order at the health centers. This situation also occurred in the other districts where the ITNs were handed out directly.

Later in the evening, all the team leaders gathered at the DHMT offices to address a number of urgent issues. For instance, in Ichimpe it was reported that the owner of the Yellow House Farmers Shop was collecting vouchers from those he suspected were over age and not issuing the ITNs. It was later revealed that his own child was vaccinated and not given an ITN since he was above the required age. In other instances, people were skipping the queue from the first table to the last table, (the ITN table), in order to collect a voucher. However, in other centers like Chambeshi, parents had to have their thumb dipped in ink to demonstrate that they had gone through the earlier stages before being issued a voucher.

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At the first review meeting, everyone agreed that the ITN component had caused a lot of confusion and that extra care had to be taken to ensure that the measles vaccination process was not derailed. The director decided that the police should be called in for the following day to help control the crowds in case the situation got out of hand again.

The following day, the crowds were abnormally large, but more controllable than the first day. This was due chiefly to the presence of the police and that people were informed that the vouchers would only be distributed to children under five. Some mothers, however, attempted to alter their child’s age on the vaccination card before reaching the ITN table. While quite a number were identified, a significant number managed to change their information before the problem was identified.

On the fourth day, the health centers located in the central district of Kalulushi (Kalulushi Township Clinic, Kalulushi Government Clinic and Kalulushi Mine Clinic) had used up their allocation of vouchers. This brought a new problem, as team supervisors started to visit health centers in the outlying areas to obtain vouchers to use as incentives for people to come to their clinic. Some of the clinics had run out of vouchers because people from the neighboring town of Kitwe came into Kalulushi District. The Chembe and Lukoshi areas also had outside people coming across district lines. Some of these people received vouchers that were meant for Kalulushi children, but most were turned away.

Health officials noted that some people had stopped bringing their children to the vaccination centers because they would not get an ITN voucher, and they decided to start door-to-door campaigns with mobile teams. The Malaria Agents were asked to explain the voucher situation to the people who gathered at the health centers thinking more vouchers would be delivered. People failed to understand why they could see the ITNs still in the outlets (waiting to be redeemed), but were told that there were no vouchers left in the health centers. Most centers reached 100% vaccination by the fifth day except for Lukoshi and Chambeshi. The sixth and the seventh days were generally very calm, and no major problems were reported relating to the distribution of vouchers or redemption of ITNs.

Results
The voucher program worked very well in reaching the target group using the commercial sector to procure, stock, and distribute the ITNs and redeem the vouchers, thus freeing the public health services to focus on the immunization campaign. Of the 14,895 vouchers distributed during this short period, the commercial partners redeemed a total of 14,792 vouchers (Cropserve 7,344) and EcoMed 7,448)—a redemption rate of 99.3%. In some cases, vouchers had to be shifted from one site to another to match the number of under-fives coming to the various clinics.

The total cost per ITN delivered was $4.88 which included the cost of the ITNs supplied to Kalulushi by the commercial partners and their redemption of the vouchers, the printing of vouchers in South Africa and their delivery to Zambia, transportation, a small payment to the Malaria Agents for their extra work, and the time of NetMark/Zambia and South Africa staff for designing and monitoring the program.

Conclusion
The task of linking ITN distribution to the measles program in Kalulushi district had its challenges; however, the close collaboration established between NetMark, the commercial partners, and the District Health Office solved problems as they arose and avoided any major hindrances to the campaign. The voucher component worked well, and the commercial partners performed admirably under a tight deadline in a district where they had no experience or existing outlets. The logistics of ITN supply, stocking, voucher distribution and redemption went very well; and the public health authorities were spared this timeconsuming and complicated process. The major problems that occurred were primarily caused by the policy of immunizing all children below 15 while only providing ITNs to children under five. The confusion over this policy combined with the intense demand for a free ITN caused a number of problems including:

----- • Mothers changing the child’s age on the measles card
----- • People coming from other districts claiming to be Kalulushi residents
----- • Using political figures to obtain vouchers by claiming to be left out of the distribution deliberately
----- • Attempts to bribe the Malaria Agents
----- • People moving from one vaccination site to another to get vouchers
----- • Supervisors moving vouchers from one vaccination site to another to please the masses
----- • Attempts to jump the designated lines (i.e., straight from the registration table to the ITN table).

Lessons Learned
----- • Vouchers can be a good addition to a public health program aimed at a specific audience. Handing out vouchers is a much easier task for the health services than managing thousands of units of a health product

----- • The distribution of free products should not be done in an area that will attract an influx of people from neighboring areas and not in a way that obviously discriminates against others participating in the same program (i.e., children above five). Such a program should be done in remote areas where the likelihood of “invaders” is reduced considerably and where the target audience (e.g., under fives) can be reached in a more subtle manner.

----- • The voucher program demonstrated how public and private sectors can work together to get a product or to the beneficiary efficiently at a low financial cost with little opportunity cost to the health services. The role of the health services was mainly to identify the areas and target audience and then to distribute the voucher to the eligible children. The commercial sector handled the complex task of procuring, stocking, and distributing the ITNs and redeeming the vouchers.

----- • Though the ITN component was accused of causing problems, the DHMT staff confessed that the
free ITNs brought out more people than they had anticipated.

----- • The ITNs were taken practically to the recipient’s doorstep by the commercial sector. Most people did not have to travel long distances to the outlet where the nets were being issued.

Looking at the events that led up to the eventual inclusion of NetMark in the Kalulushi pilot ITN voucher component, this program should be commended for its ability to deliver in a short period of time.

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