title: Operational challenges to continuous LLIN distribution: a qualitative rapid assessment in four countries.
abstract: BACKGROUND
  The World Health Organization recommends that long-lasting insecticidal nets (LLINs) for malaria prevention should be distributed continuously through antenatal care (ANC) and the expanded programme on immunization (EPI) in addition to mass campaigns. Despite these recommendations, the continuous distribution (CD) of LLIN distribution through ANC and EPI is not policy in many countries, and where there is a policy, implementation is incomplete. This study aims to identify the operational strengths and weaknesses of LLINs CD in four country programmes in sub-Saharan Africa.
  
  
  METHODS
  A qualitative rapid assessment process was conducted using semi-structured individual and group interviews at the national, sub-national, and facility level in four countries. Seventy participants were included (23 in Kenya, 13 in Malawi, 18 in Mali and 16 in Rwanda), drawn from malaria programmes, ANC and EPI programmes, government logistics units, and partner organizations. Interviews were structured to identify themes within a health systems approach. Policy and guideline documents and data collection tools were reviewed as a means of triangulation. Data analysis focused on pre-determined and emergent themes.
  
  
  RESULTS
  The four countries used a wide variety of management systems for the supply of LLINs to routine services. Issues related to quantification, supply logistics and data collection all contributed to stock-outs at facility level. None of the four countries had guidelines for responding to stock-outs or system enabling local staff to request additional supplies of LLINs. In all four countries, data collection of LLIN distribution was incomplete or absent at facility level, and such data were not used for planning. Training of staff at the facility level was implemented less frequently than national and sub-national staff would have preferred. Logistics systems, independent of other commodities, and in-country partner support strengthened the continuous distribution of LLINs.
  
  
  CONCLUSIONS
  In these countries, stock-outs were the most important single obstacle to the smooth operations of continuous LLIN distribution. Stock-outs can be avoided if facilities have the capacity to place orders for LLIN resupply as needed. Revised data collection and management systems for LLIN distribution have the potential to increase coverage of the target populations by improving LLIN stock-out response, and strengthening monitoring and evaluation of distribution.
authors.affiliation: Infectious Disease Epidemiology Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK. katherinetn@gmail.com.
authors.forename: Katherine
authors.initials: K
authors.lastname: Theiss-Nyland
authors.affiliation: Malaria Control Unit, Ministry of Health, Nairobi, Kenya. abbadhullo@yahoo.com.au.
authors.forename: Waqo
authors.initials: W
authors.lastname: Ejersa
authors.affiliation: Malaria and other Parasitic Diseases Division, Rwanda Biomedical Centre, Kigali, Rwanda. ckarema@gmail.com.
authors.forename: Corine
authors.initials: C
authors.lastname: Karema
authors.affiliation: Programme National de Lutte Contre le Paludisme, Ministere de la Sante et l'Hygiene Publique, Bamako, Mali. dkone1311@yahoo.fr.
authors.forename: Diakalia
authors.initials: D
authors.lastname: Koné
authors.affiliation: Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. hkoenker@jhu.edu.
authors.forename: Hannah
authors.initials: H
authors.lastname: Koenker
authors.affiliation: Tropical Health LLP, London, UK. yvescyaka@yahoo.fr.
authors.forename: Yves
authors.initials: Y
authors.lastname: Cyaka
authors.affiliation: Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. mlynch@jhu.edu.
authors.forename: Matthew
authors.initials: M
authors.lastname: Lynch
authors.affiliation: Disease Control Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK. jayne.webster@lshtm.ac.uk.
authors.forename: Jayne
authors.initials: J
authors.lastname: Webster
authors.affiliation: Disease Control Department, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK. jo.lines@lshtm.ac.uk.
authors.forename: Jo
authors.initials: J
authors.lastname: Lines
mesh_terms: D017954:Africa South of the Sahara; D006302:Health Services Research; D006801:Humans; D057148:Insecticide-Treated Bednets / Q000706:statistics & numerical data; D008288:Malaria / Q000517:prevention & control*; D009032:Mosquito Control / Q000379:methods / Q000458:organization & administration / Q000706:statistics & numerical data