How Zanzibar is using data-informed strategies to reach every household with insecticide-treated nets to eliminate malaria
By: Irene Kemilembe, Senior Program Assistant, Digital Square at PATH
The supportive supervision team in Pete, Zanzibar. From right to left: Salim Faki Salim (ZAMEP), Jacqueline Madundo (TVCA), Lulu Msangi (PMI USAID), Mwanamgeni Haji (RA), Mwanahamisi Mussa (RA), Salama Ally (RA),Salami Khatib Hassan (RA) , Caroline Mshanga (BA), Shahada Kinyaga (BA), Musa Salehe Mihambo (Sheha), Salami Khatib Hassan (RA)Shalabu Hassan (RA), Irene Kemilembe (PATH-Digital Square), Ali Omar Hamad (District Planning Officer), Nicholaus Mwenda (MonitAfrica). Photo: PMI
Although Zanzibar has a low malaria burden—with a test positivity rate of less than 1.0 percent among people seeking health services in 2021—it has remained relatively stagnant over the past several years. In an effort to eliminate this disease, the U.S. President’s Malaria Initiative (PMI) has introduced new efforts including the procurement of dual active ingredient (AI) insecticide-treated nets (ITNs). This is in line with the 2018–2023 Strategic Plan IV of the Zanzibar Malaria Elimination Program (ZAMEP) and the new strategy under development (2024–2028).
To support these malaria elimination efforts, Digital Square at PATH—with funding from PMI through the U.S. Agency for International Development (USAID)—worked with the Ministry of Health (MOH) Zanzibar to develop an innovative digital system to plan, register, quantify, and issue ITNs for the ZAMEP. The resulting Mass Replacement Campaign (MRC) ITN System transformed the traditional paper-based registration and distribution process to a cutting-edge digital platform. In collaboration with ZAMEP-MOH Zanzibar, the Johns Hopkins University’s (JHU) Breakthrough ACTION project (BA), the JHU PMI Vector Control project (TVCA), and MonitAfrica, Digital Square helped develop the MRC ITN System to streamline data capture across the Zanzibar archipelago isles of Unguja and Pemba.
The MRC ITN Campaign System was first introduced in June 2023 and is now being used across 314 shehias, which are defined as administrative areas constituted by one or more villages in Zanzibar. Following the system's launch, program officials had immediate access to household registration data disaggregated by zone, district, and shehia, a process that previously took multiple days using the traditional paper-based system.
ITN Distribution Manager Jacqueline Anita Madundo (PMI Tanzania Vector Control Project) and Bishara Hemed Hamid (Assistant Head SBC Unit ZAMEP) use the MRC ITN campaign system dashboard to identify the targeted shehias that require supportive supervision to ensure that all households in Unguja are registered for net distribution. ZAMEP office, Zanzib. Photo: PATH/Irene Kemilembe
Identifying and registering target shehias
Between April 15 and 19, 2024, Digital Square joined partners from PMI USAID, ZAMEP, TVCA, BA, and MonitAfrica to conduct targeted supportive supervision visits in shehias with the lowest household registration. The shehias were identified using the MRC ITN Campaign System dashboard, which provides ZAMEP and its implementing partners with access to real-time registration data and visualizations. By using the dashboard to monitor household registration data, teams could deploy the resources and support needed to resolve challenges in low-performing areas.
Salim Faki Salim (SBC Officer, ZAMEP) and Nicholaus Mwenda (Business Analyst, MonitAfrica) provided technical support to Idrissa Haji (Registrant Assistant) in Pete Shehia. Photo: PATH/Irene Kemilembe
During the supportive supervision visits, Digital Square and MonitAfrica provided technical assistance to Shehas (local leaders who are responsible for regional administration) and Registrant Assistants (RA) in the targeted shehias. For example, the dashboard revealed that Pete Shehia in Kati District had not registered a single household yet. An RA and Sheha supported the provision of new usernames and passwords to login into the mobile application, granting workers access to the application. The joint supportive supervision visit resulted in an increase in the household registration rate in Pete Shehia from 0 percent on Monday, April 15 to 88 percent on Friday, April 19.
Idrissa Haji (Registrant Assistant, Pete Shehia) registers the first household using the MRC ITN Campaign System (all personal data have been blurred). Photo: PATH/Irene Kemilembe
MRC ITN Campaign System dashboard showing the 88.08 percent household registration rate in Pete Shehia as of Friday, April 19th.
Promoting registration through messaging
Example of an SBC SMS message in Swahili that reads, “Hello Brother, you are NOW registered to receive mosquito nets from ZAMEP. Your coupon number is 26920304. Please keep that number as the one that will be used on the day of distribution.” Photo: PATH/Irene Kemilembe
The MRC ITN Campaign System also supports social and behavior change (SBC) interventions. Once registered, an SMS message is sent to the head of the household to confirm their registration and provide them with a coupon number to use as identification during the process to issue bednets.
According to the PMI Tanzania (Zanzibar) Malaria Operational Plan from FY2022, in 2017, only 42% of households had at least one ITN for every two people indicating that there is an opportunity to expand the usage of ITNs as an effective malaria prevention strategy. In 2017, 59 percent of the population of Zanzibar were sleeping under an ITN every night, despite 62 percent of the population having access to an ITN. This demonstrates the need to engage SBC strategies like SMS messages in local languages to encourage consistent use of ITNs. This project is supporting many of PMI’s SBC objectives, which are:
To increase the proportion of people who believe that ITNs are effective at preventing malaria when used consistently and correctly.
To increase the proportion of people who believe that ITNs should be used. consistently every night in all seasons
To increase the proportion of people who know how to properly care for their ITN and replace it when damaged.
Next steps for the system
As of April 24, 2024, the MRC ITN Campaign System had registered a total of 290,314 households and identified a total of 865,164 ITNs needed across 314 shehias in Unguja and Pemba. ZAMEP and their partners are already using the tool to inform their decision-making processes. For example, the ZAMEP team, USAID, and TVCA used the system to prioritize ITN distribution to shehias that had the highest malaria burden.
The team looks forward to continuing to use the system during ITN campaigns and scale up its use for SBC interventions to improve households’ ITN usage for malaria prevention.
Mwinyi Khamis (SBC Head ZAMEP), Sarah Blythe Ballard (CDC Resident Advisor), Naomi Serbantez (PMI Advisor), and David Dadi (Chief of Party TVCA) during the MRC Campaign update meeting at the ZAMEP office in April 2024. Photo: PATH/Irene Kemilembe