1. LLIN Continuous Distribution
The gap between policy and practice
Katherine Theiss-Nyland
LSHTM
Infectious Disease Epidemiology
Improving health worldwide

2. Background WHO recommends that: But in countries with such a policy:
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

3. 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.

4. 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 (23)
Sub-national health office (16)
NMCP staff (12)
MCH/Repro.hlth national staff ( 4)
EPI national staff ( 3)
Logistics national staff ( 8)
NGO national staff ( 8)

5.   Distribution of LLINs through ANC vs EPI ANC EPI
Global Recommendation 
Specific timing recommendation for ANC distribution 
No timing recommendation for EPI distribution
Policy
LLILNs included in ANC policy
LLINs NOT included in EPI policy
Management
LLINs Managed by ANC and Malaria programmes
LLIN NOT managed by EPI programme
Monitoring
LLIN distribution data collected and used by ANC and Malaria programmes
LLIN data NOT collected or used by EPI
Supervision
Joint supervision by Malaria and ANC
NO joint supervision
Data Collection
ANC registers include LLIN distribution to pregnant women
EPI registers do not include distribution to infants
Data reporting and use
ANC-based LLINs reported for ANC programme monitoring
EPI-based LLINs are not used for EPI programme monitoring

6. 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
“A pull system would be the best, because certain factors may not be taken into account at the central level.” (National Product Logistics, Rwanda)
No stock out response system
“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)
Stock outs and decreased uptake of ANC and EPI
“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)

7. LLIN supply chain for routine distribution
KENYA
MALI
MALAWI & RWANDA
Sub-county orders from NMCP;
NMCP sends LLINs to Facilities from regional storage warehouses.
Request from Facility to District and
from District to NMCP.
NMCP “corrects” order based on availability and national data and sends LLINs to District.
District sends LLINs to Facility based on availability
NMCP sends LLINs to Facilities based on national distribution plan. (NB Malawi uses decentralized storage spaces).

8. Conclusion Stock-outs at facilities ANC out-performing EPI
- Allow facilities to place orders
- Create stock-out response systems
ANC out-performing EPI
- Involve EPI in LLIN distribution
- Record LLIN handling in EPI book
Limited routine M&E of CD
- Routine comparison of the # of LLIN distributed against # of women and # of children attending ANC and EPI

9. Thank you Specific Thank yous and acknowledgements to: Malawi: Rwanda:
LSHTM:
Doreen Ali
Corine Karema
Jayne Webster
Antonia Powell
Dr. Monique Murindahabi 
Jo Line
Charles Yuma
Mali:
Johns Hopkins/Net Works:
Diakalia Koné
Hannah Koenker
Facility and regional and national staff in each country
Matthew Lynch
Kenya:
Sara Berthe
Waqo Ejersa
Anne Musuva
Trop Health:
Staff at PSI and PSKenya in each country
Rebecca Kiptui
Yves Cyaka
James Mwangi
Albert Killian
Caroline Vandrick