LLIN Continuous Distribution
The gap between policy and practice
Katherine Theiss-Nyland
LSHTM
Infectious Disease
Epidemiology
Improving health worldwide
www.lshtm.ac.uk
Background
• WHO recommends that:
– LLINs should be distributed continuously through routine
ANC and EPI channels, in addition to mass campaigns;
– Distribution through ANC and EPI should be active before,
during, and after campaigns;
– An LLIN to be given to every woman attending ANC, and
every child attending EPI.
• But in countries with such a policy:
– Only 45%* of pregnant women actually get an LLIN from
ANC;
– Only 34%* of infants get an LLIN from EPI
*World Malaria Report 2013
Purpose and Objectives
Investigate the gap between policy and practice:
what are the operational barriers and bottle-necks limiting
implementation of LLIN distribution through ANC and EPI ?
• Describe the structures and processes used in a few
different countries
• Compare and contrast between ANC and EPU
• Identify strengths and weaknesses, obstacles and
opportunities.
Methods
• Countries: Mali, Kenya, Rwanda, Malawi
• Qualitative, Rapid Assessment Process
• Key informants purposively selected to include a range of
agencies, roles and levels (national/local)
• Semi-structured interviews: individual and small groups
• 23 Interviews with 70 staff:
– Local health facility staff
– Sub-national health office
– NMCP staff
– MCH/Repro.hlth national staff
– EPI national staff
– Logistics national staff
– NGO national staff
(23)
(16)
(12)
( 4)
( 3)
( 8)
( 8)
Distribution of LLINs through ANC vs EPI
ANC
Global
Recommendation
Policy
Management
Monitoring
Supervision
Data Collection
Data reporting
and use
EPI

Specific timing
recommendation for ANC
distribution

No timing recommendation
for EPI distribution

LLILNs included in ANC
policy

LLINs NOT included in EPI
policy

LLINs Managed by ANC and
Malaria programmes

LLIN NOT managed by EPI
programme

LLIN distribution data
collected and used by ANC
and Malaria programmes

LLIN data NOT collected or
used by EPI

Joint supervision by Malaria
and ANC

NO joint supervision

ANC registers include LLIN
distribution to pregnant
women

EPI registers do not include
distribution to infants

ANC-based LLINs reported
for ANC programme
monitoring

EPI-based LLINs are not
used for EPI programme
monitoring
Operational barriers to service delivery
Incomplete
facility data
“The major challenge now is that there are many books to write in, when
we collect data, and people sometimes get lazy to fill all the registers
correctly.” (District Health Office, Malawi)
Inaccurate
national
estimates
“You find that it is difficult to have accurate data about the consumption
at the operational levels, to be able to make proper quantification at
national level. So often we have to estimate” (NMCP, Mali)
Facilities cannot
place orders
No stock out
response
system
Stock outs and
decreased
uptake of ANC
and EPI
“A pull system would be the best, because certain factors may not be
taken into account at the central level.” (National Product Logistics,
Rwanda)
“ITN ... sometimes go out of stock ... When they bring, sometimes they
bring on time, sometimes it could have a delay of one month, two months.
We have to wait until it comes” (Facility head, Kenya)
“After some time, we started to face stock out [of nets] and financial
problems and the people stopped visiting the health centres [for ANC]”
(District health officer, Mali)
LLIN supply chain for routine distribution
KENYA
(1) Sub-county orders
from NMCP;
(1) NMCP sends LLINs
to Facilities from
regional storage
warehouses.
MALI
(1) Request from Facility to
District and
(2) from District to NMCP.
(3) NMCP “corrects” order
based on availability and
national data and sends
LLINs to District.
(4) District sends LLINs to
Facility based on
availability
MALAWI & RWANDA
(1) NMCP sends LLINs
to Facilities based on
national distribution
plan. (NB Malawi
uses decentralized
storage spaces).
Conclusion
Stock-outs
at facilities
ANC outperforming
EPI
Limited
routine
M&E of CD
- Allow facilities to place orders
- Create stock-out response systems
- Involve EPI in LLIN distribution
- Record LLIN handling in EPI book
- Routine comparison of the # of LLIN
distributed against # of women and
# of children attending ANC and EPI
Thank you
Specific Thank yous and acknowledgements to:
Malawi:
• Doreen Ali
• Antonia Powell
• Charles Yuma
Rwanda:
• Corine Karema
• Dr. Monique
Murindahabi
Mali:
• Diakalia Koné
Johns Hopkins/Net Works:
• Hannah Koenker
• Matthew Lynch
• Sara Berthe
Kenya:
• Waqo Ejersa
• Anne Musuva
• Rebecca Kiptui
• James Mwangi
Trop Health:
• Yves Cyaka
• Albert Killian
• Caroline Vandrick
LSHTM:
• Jayne Webster
• Jo Line
Facility and regional and
national staff in each country
Staff at PSI and PSKenya in
each country