Increasing Access to Mosquito Nets through Schools to Fight Malaria in Liberia

ITNs are an effective public health tool for preventing malaria as they provide both physical and chemical barriers against mosquitoes. A Liberia Demographic and Health Survey (LDHS) published in 2021, however, reported that only 55% of Liberians had access to ITNs, either through the routine distribution to health facilities for antenatal care (ANC) and postnatal care (PNC) or mass distribution campaigns to households, which have been conducted every three years in Liberia since 2015.

To increase household access to ITNs, the Liberia National Malaria Control Program, with technical support from the U.S. President’s Malaria Initiative (PMI), identified school-based net distribution as an efficient delivery channel. In November 2021, PMI in Liberia through the USAID Global Health Supply Chain Program-Procurement and Supply Management (GHSC-PSM) project, and in collaboration with other partners, including the Liberia National Malaria Control Program (NMCP) of the Ministry of Health, READ Liberia, Breakthrough Action Liberia, and the Central Medical Store (CMS), piloted school-based net distribution in Montserrado county.

“This path to safety from malaria was particularly important,” recalls Dr. Francis Kateh, Chief Medical Officer of Liberia. “Available data indicated that the routine ITN distribution through ANCs and institutional delivery was inadequate to reduce the ITN access gap and maintain high ITN access between mass campaigns.”  Between 2019 and 2020, among the 55% of households with ITNs, 30% did not have enough ITNs to cover all the household members, as reported in the LDHS 2019-20. This meant that only 25% of the households had adequate access to nets (one net per two people).

The LDHS also showed that while net use was higher among pregnant women (47%) and children under the age of five years (44%), it was lowest among those aged 5–14 years (34%) – the age range for most school-going children. This demonstrated that school-aged children and adolescents had the lowest ITN use when households had insufficient ITN coverage. According to the Liberia Education Statistics Report 2019/2020 of the Ministry of Education, 91% of the 1,452,453 students who enrolled in Liberian schools for the 2019/2020 academic school year fell in the age range of 5–14 years, covering the education levels of early childhood and lower and upper basic education. School-going children at those education levels fall between grades 1 and 9. This formed the basis for adopting the strategy of school-based ITN distribution in mitigating the observed access gap, targeting students of grades 1, 5, and 9. 

After the pilot in Montserrado County, GHSC-PSM worked with the National Malaria Control Program (NMCP) of the Ministry of Health (MOH) and the Health Education Unit (HEU) of the Ministry of Education (MOE) to develop and implement a strategy for ITN distribution to students. The initiative was extended to Bong, and Nimba Counties in December 2022, selected due to low access to ITNs and having the highest number of schools and enrollment population.

According to the Liberia Education Statistics Report of 2019/2020, there were 6,296 schools in Liberia with a national enrollment of 1,452,453. Montserrado had the highest number of schools (2,310 or 36.7% of the total) with an enrolment of 541,963 (37.3%), followed by Nimba (787 or 12.5%) with an enrolment of 183,551 (12.8%), and Bong (459 or 7.3%) with an enrolment of 122,975 (8.6%). Though no baseline data existed related to students’ access to ITNs, data on overall access across the populations of the three counties were available, with Montserrado at 26%, Bong at 48%, and Nimba at 51%, as reported in the LDHS 2019/2020. 

As part of providing technical assistance for the development and implementation of the school-based ITN distribution, GHSC-PSM also supported an orientation on school-based social behavior change by Breakthrough Action. The orientation focused on training select school coordinators on the appropriate care and use of nets, who in turn taught their students, who then shared the information with their parents and siblings at home. In this way, both students and teachers serve as champions to increase net access and promote net use in households to fight malaria.
 

   School-based social behavior change training. Photo credit: GHSC-PSM

GHSC-PSM supported the quantification (forecasting and supply) of ITNs for distribution and the collection and cleaning of schools’ enrollment data. Support was also provided for the development and implementation of distribution plans, tools, utilization, and the deliveries of ITNs to county depots and district storage facilities. Further assistance was made available for the production of a report on the final distribution. Additionally, the project ensured the safe disposal of the nets’ plastic wrappings after assessing and mapping available incinerators in the three counties.

GHSC-PSM worked with the MOH and MOE to distribute a total of 112,423 nets to 1,331 schools between December 2021 and March 2023. This meant that 106,078 students and 6,345 teachers now had direct access to and ownership of ITNs. Prior to the distribution, many students enrolled in the targeted early childhood, basic, and upper education facilities in Montserrado (59,247), Nimba (36,678), and Bong (21,391) had insufficient access to ITNs as established by enrollment data obtained from each of the three county education teams.  90.4% of targeted students (out of a total of 117,316) and 96.9% of their teachers (out of a total of 6,544) received ITNs as a result of the campaign. The 1,331 schools to which ITNs were delivered in Bong (444), Montserrado (129), and Nimba (758) constituted 94% of early education facilities of a targeted total of 1,415 schools in the three counties. 

ITNs distribution to students at John Flomo Bakalu School. Photo Credit: GHSC-PSM

While the extent of the impact of the school-based ITN distribution is being recommended for full assessment by the Government of Liberia and PMI, Chrispin Williams, Vector Control Coordinator at the NMCP believes the initiative is noteworthy. “The distribution of ITNs through schools is a further step forward in increasing the uptake of nets utilization in Liberia, which in turn, is contributing to reducing the incidence and treatment of malaria cases in Liberia,” he said. 

Alben Sibley, Senior Technical Advisor of USAID GHSC-PSM in Liberia shared that the implementation of the campaign was not without challenges. To overcome the hurdle of obtaining school enrollment data at the central level, GHSC-PSM engaged with the county and district education officers at the sub-national level. Challenges related to delays in county health teams (CHTs) undertaking the required school-based communication orientation training before the distribution of ITNs in schools were addressed by GHSC-PSM and the NMCP developing a training schedule that did not interfere with the work of the CHTs. A challenge of incoherent application of school-based communication (SBC) information by school coordinators was resolved by revising the distribution strategy from instant distribution of nets to pre-positioning of nets to schools, and advising that distribution does not commence until the completion of SBC orientation. 

The schools’ authorities were informed by GHSC-PSM and the NMCP monitoring team that the nets were intended for all students regardless of the status of their financial obligations to the schools, hence resolving the issue of students being denied access to ITNs due to non/partial-payment of school fees. Additionally, the problem of general misconception that the nets were being used to spread COVID-19 by pharmaceutical companies in an effort to create demand for their health products and increase profitability, was also countered through community engagement and public awareness campaigns in the media and during the school-based social behavior change communication orientation. 

“This misconception,” recalls Alben, “was mostly prevalent in the communities outside Liberia’s capital Monrovia. To address this, the consortium of partners of the school-based ITN distribution provided relevant health information about the effects of malaria and the use of LLINs to prevent and control malaria, emphasizing that ITNs are not harmful to humans but lethal to mosquitos.” 

Lessons were also learned during the distribution exercise, including the need to ensure that school enrollment data are collected within two or three months after the resumption of academic activities to reflect the reality of enrollment by the time the distribution is implemented. The distribution of nets should also be implemented at least two weeks from the students’ examination period to ensure instant distribution and timely collection of distribution forms. 

As Liberia prepares to undertake the mass distribution of ITNs in 2024, GHSC-PSM will, based on funding availability, continue to work with the NMCP to expand school-based distribution across Liberia’s fifteen counties, especially those with low net access and high school enrollment numbers.

The Government of Liberia has since adopted the school-based ITN distribution approach in its Malaria National Strategy Plan (MNSP) for 2021-2025. According to the Liberian Government, “This school-based ITN distribution strategy will contribute to the second MNSP objective of reducing malaria case incidence by at least 75% (95/1,000 population) compared to 2016 (380/1,000 population).”  With a goal to ensure universal access to ITNs for all Liberians, the Government aims to provide ITNs through schools to 80% of counties and students with low net access in the selected counties to enhance ownership and coverage of ITNs.

GHSC-PSM plans to regularly monitor and evaluate the effectiveness and efficiency of the school-based ITN distribution and continue to identify best practices and address the challenges and barriers to the implementation and uptake of the program.

The fight against malaria in Liberia is progressing as the latest Liberia Malaria Indicator Survey 2022 shows that ownership of ITNs has increased from 55% in 2019/2020 to 72% in 2022, with access to nets also increasing from 47% in 2019/2020 to 52% in 2022.