Revolutionizing malaria elimination in Zanzibar: Success of the Mass Insecticide-Treated Nets Distribution System
By: Sophie Bochaberi, Communications Officer, Digital Square at PATH
Representatives from the Tanzania Ministry of Health, Community Development, Gender, Elderly and Children; Mjini Magharibi regional government; US Agency for International Development; and Zanzibar Malaria Elimination Programme at the launch of the Mass Replacement Campaign insecticide-treated net distribution campaign in Zanzibar, along with beneficiaries. Photo: Tanzania Vector Control Activity.
In the picturesque landscape of Zanzibar, a groundbreaking initiative finds success in combating one of the world's deadliest diseases: malaria. According to the World Health Organization, malaria is the largest killer in Africa, with an estimated 619,000 deaths yearly (2021), most of whom are children under five years of age. For the almost 1 million residents of Zanzibar, disease-borne vectors such as mosquitos pose a real threat of an infection that can lead to severe disease or death.
Over the years, with support from the US President’s Malaria Initiative and its partners, the Government of Zanzibar has strived to mitigate malaria deaths by emphasizing prevention through distribution of insecticide-treated nets (ITNs) to populations in high malaria-burdened regions. The Zanzibar Malaria Elimination Programme (ZAMEP), housed within the Zanzibar Ministry of Health, Social Welfare, Elderly, Gender and Children, has spearheaded these ITN distribution campaigns to control the spread of the disease in the region.
Making the move from paper to digital
In previous campaigns, which relied on paper-based tools, ZAMEP faced challenges in managing the registration of households eligible to receive ITNs. From data inaccuracy and inaccessibility to storage and retrieval difficulties, these challenges resulted in reporting delays. Timely reporting is crucial to ensure timely and cost-effective distribution of ITNs. ZAMEP needed to leverage data-driven solutions to eliminate common human errors and discrepancies, which had previously hindered the success of malaria control campaigns.
"Insecticide-treated nets are key drivers in eliminating malaria in Zanzibar households,” stated Nassor Ahmed Mazrui, Zanzibar Minister of Health. “Through close collaboration with our partners, we are committed to the adoption of innovative digital health technologies that strengthen our health systems to meet the unique needs of our local communities."
“We are committed to the adoption of innovative digital health technologies that strengthen our health systems to meet the unique needs of our local communities.”
Early in 2023, ZAMEP embarked on a mission to reshape the vector control and prevention landscape. With funding from the US Agency for International Development (USAID), Digital Square at PATH collaborated with ZAMEP to design and develop an innovative digital platform—the Mass ITN Distribution System—to streamline the data capture process for planning, user registration, and distribution of ITNs to households across the region's 53 shehias (wards).
On July 25, 2023, the Usingizi Bul Bul campaign (“A Restful Night’s Sleep” in Swahili) kicked off with an enthusiasm that echoed the island's desire to rid itself of the malaria burden by deploying the Mass ITN Distribution System. The campaign covered three districts within the Mjini Magharibi Region of Zanzibar: Magharibi A, Mjini, and Magharibi B.
“The Usingizi Bul Bul campaign embodies our dedication to malaria elimination in Zanzibar. The United States remains committed to helping move toward a malaria-free future in Zanzibar, and we urge Zanzibaris to ensure they receive their ITNs and sleep under them every night for ‘Usingizi Bul Bul,’” stated Anna Hoffman, Acting Director for the USAID/Tanzania Health Office.
How it works
The Mass ITN Distribution System includes several features to support improved data accuracy and use:
A registration assistant uses an app to log household data. Photo: PATH/Sadick Masomhe.
A user-friendly mobile application allows easy access and management of all collected data. Field registration assistants collect household data, monitor progress, and approve data directly, ensuring real-time data capture and sharing. All collected data are saved directly into the live database for easy access and management by ZAMEP officials.
The system is integrated into an SMS gateway that instantly sends SMS notifications to all registered households. The message asks the recipient to verify his or her registration and provides a unique coupon number (an eight-digit identifier). It also includes an estimate of the number of ITNs that will be issued to that household.
Active case surveillance and monitoring of households registered for ITN distribution allow ZAMEP staff to track and monitor the progress of data collection and its effectiveness. Additionally, shehia leaders are able to track and manage ongoing registration within their shehas and the larger wards in which they are housed.
Real-time data collection, integration, and management of households provide timely and accurate data analysis for evidence-based decision-making. All the collected data are centrally stored and managed and can be accessed at any point via a web application that provides role-based accessibility.
The system generates comprehensive reports and analytics, enabling ZAMEP to assess campaign performance, monitor key indicators, and identify trends for informed planning and efficient resource allocation.
Figure 1: Mass ITN Distribution System dashboard
The results
Registration of households kicked off on July 3 and ended on July 14, 2023. This timeline was significantly shorter than previous years, which required longer registration periods. A total of 53 shehia leaders were registered to supervise the activities, and 217 registration assistants were enrolled in the Mass ITN Distribution System. This allowed them to use the mobile application while going door to door to register all households in the selected regions.
Registration assistants during a training session in Mjini Magharibi. Photo: PATH/Sadick Masomhe.
Registration assistants also could check progress and adjust their strategies via a dashboard (Figure 1) that shows the targeted number of households to be registered and the percentage of progress toward that goal. As of July 14, 82,199 households had been successfully registered.
The Mass ITN Distribution System lets shehia leaders track registration using a user-friendly interface. Shehia leaders are responsible for validating and authenticating household data, ensuring accuracy and completeness. The system's design prevents errors and calculates the number of ITNs required for each household, adhering to a 2:1 ratio (one ITN for two people, as recommended by the World Health Organization).
Monitoring registration activities at the ZAMEP level was made possible through the use of a web application. The application compared the baseline data with the registered households and population data to identify locations that were lagging behind. This process helped provide timely advice on measures that could be taken to complete the activity within the given time frame. By using the system, ZAMEP and other stakeholders had access to live data, which gave them the flexibility to reallocate resources at any point in time, as necessary, to ensure smooth implementation of the campaign and successful distribution of 246,483 nets, per the targeted goal.
Overcoming obstacles through collaboration
While the journey was ultimately transformative, technical and user challenges emerged during the initial days of deployment. Swift intervention was necessary to deal with technical glitches. A team from MonitAfrica, a local technical partner working with Digital Square, provided that support. The synergy between ZAMEP, USAID’s Tanzania Vector Control Activity, MonitAfrica, and the field teams was instrumental in overcoming these hurdles. WhatsApp groups facilitated constant communication, ensuring issues were promptly identified and resolved. All parties shared an unwavering commitment to success, which paid off in the successful deployment of the system.
“At Digital Square, we work closely with country governments to develop and design digital health solutions that are tailored to meet specific country needs and priorities,” said Sadick Masomhe, Senior Program Officer at Digital Square, Tanzania. “To achieve this goal, we are engaging with local digital health entrepreneurs, like MonitAfrica, to provide localized digital solutions and diversify the ecosystem.”
The Mass ITN Distribution System's success marks a significant milestone on the path to malaria elimination. By harnessing technology, data, and the spirit of collaboration, ZAMEP sets an inspiring precedent for disease control and prevention.