Introduction to Continuous ITN Distribution
This section summarizes continuous distribution (CD). For a more detailed overview, including supply modality, channel, duration, target, cost to user, mode of delivery, choice for user, and sector, see Continuous Long-lasting Insecticidal Net Distribution: A Guide to Concepts and Planning.
CD plays a vital role in maintaining universal ITN coverage. The term ‘continuous distribution’ encompasses a range of channels for ITN delivery. Planners must consider the country needs and contexts in order to select the most appropriate approach(es) to CD as part of a coherent ITN strategy. CD approaches should be designed and managed in consideration of the overall ITN plan and plans for other CD channels. This is a key point to keep in mind at all stages of design, planning, and implementation.
What is continuous distribution (CD)?
The World Health Organization (WHO) recommends that both large-scale mass distribution campaigns and continuous distribution (CD) be implemented as part of a multi-channel strategy to achieve and maintain universal access to insecticide-treated nets (ITNs). Continuous distribution strategies employ channels other than mass campaigns to deliver ITNs, and encompasses routine ITN delivery at antenatal clinics (ANCs) and immunization visits (EPI) schools, community-based programs, and sales within private sector, including social marketing.
A Framework for Classifying and Describing Distribution Mechanisms
Numerous different mechanisms have been used or proposed for continuous ITN distribution. All distribution mechanisms have various options for components which should be chosen according to the needs and context of the setting. Kilian et al., 2009 describe a system to categorize ITN delivery mechanisms, in which each mechanism is defined by six criteria (delivery channel, duration, target population, cost to user, choice, and sector). Several delivery mechanisms can be combined to reach a specific overall malaria strategic objective.
Challenges in continuous ITN distribution
Continuous distribution of ITNs has been seen as an important part of an overall ITN strategy since the early 2000’s. Many countries have considerable experience, for many years, implementing some form of continuous ITN distribution. Despite the years of collective and country-individual experience, most CD programs still struggle to maintain high quality service. This is seen in frequent stockouts, challenges with reporting and accountability, and uptake and impact on equity and access. Specific challenges to remember when planning and managing CD programs are—
- Ensuring even, uninterrupted funding, which can avoid gaps in funding to meet national needs for ITNs, logistics, and operations.
- Ensuring timely disbursement of funds to avoid delays and reductions of funding for ITN procurement, port clearance, transport, and other logistics and operations.
- Ensuring clarity in budgeting to cover the additional costs of malaria services via the existing channels.
- Avoiding duplication of effort in planning, tools, resource development, training, and support supervision for multiple CD channels that are designed and rolled out at different times.
- Ensuring and maintaining ‘ownership’ by regional, district, or other relevant staff who view ITN distribution as the responsibility of the National Malaria Control Program (NMCP) or a particular donor, and not part of an integrated health package, a community responsibility, or school involvement.
- Avoiding decreased motivation or general lowering of standards of service, as a result of over-burdening personnel particularly at health facility staff. They often have a role to play in most, if not all, other CD channels—potentially, in supervision, resupplying of stock and materials, data management, training and refresher training, and monitoring and evaluation (M&E).
- Maintaining stock levels of both ITNs and associated monitoring materials.
- Maintaining high levels of transparency and accountability to prevent, detect, and mitigate the impact of fraud, theft, or diversion of ITNs.
- Minimizing non-target groups receiving ITNs because too much diversion can complicate quantification and planning, and can concern donors.
- Managing community awareness and perspectives on—
- Why ITNs are only available to certain target groups.
- Where ITNs are and the eligibility—encouraging uptake.
- Passing ITNs to other families when one’s family has sufficient access.
Many of these difficulties relate to financing, procurement, and supply management, which must be significant areas of focus in planning and managing CD. Coordination mechanisms should be used to mobilize a group of committed and engaged stakeholders; they can provide support on a continuous basis to review progress, find solutions when problems arise, and plan for contingencies to avoid problems before they arise. Advocacy messaging from a range of partners can help build a sense of collaboration and joint purpose among key stakeholders, making some of issues easier to resolve.
Common CD approaches
The most common CD channels currently used are routine health facility channels, specifically distributions to ANC or EPI clients, community-based distributions using a range of community structures, school distributions to school pupils, and working with and through the private sector to ensure quality ITNs are widely available and affordable on the open market. This Table describes some of the features of each of these mechanisms, including examples of countries that have used this approach.
It is recommended that, wherever feasible, routine health facility–based distribution—to pregnant women through ANC and to infants at EPI visits, are the prioritized channels for a CD approach to ensure that biologically vulnerable populations always have access to ITNs. Other complementary options may be added, as needed, because the ANC and EPI distribution channels alone cannot sustain universal access without mass campaigns.
Whatever mix of channels are selected, the importance of close linkages throughout the planning and management cycle is stressed; it should be remembered at all times. For a reminder on how the different channels are interlinked, see table below.
Benefits and potential drawbacks of routine ITN distribution
Routine ITN distribution is done through ‘routine’ channels (i.e., channels already established for other routine services, usually health facilities). Including ITN distribution in routine health service delivery has a number of potential benefits, including those presented in the table below. Also consider the potential drawbacks of including ITNs in routine health service delivery when developing and implementing a routine ITN distribution program to ensure that safeguards and other mechanisms to mitigate these can be put in place.
|Access||ITN delivery via ANC and EPI services increases access for two biologically vulnerable groups: pregnant women and children under one year of age.|
|Attendance||While use of health services varies from country to country, routine ANC and EPI access is relatively high in many countries; on average, more than 80% of pregnant women attend at least one ANC visit and more than 70% of children have at least three vaccination contacts (DPT3) in most (87%) countries.|
|Distribution||Working within established national health systems supports ITN delivery through pre-existing structures with secure storage and trained personnel. In some cases, existing structures are supported by additional systems (e.g., via malaria partners, the commercial sector), particularly to ensure warehousing and transport of ITNs from port to regional- or district levels.|
|Education and promotion||Trained health personnel leverage their unique and established consultation opportunity with mothers and caregivers to provide key malaria information and to promote ITN use. Likewise, from the health workers and managers perspective, providing a continuous supply of free, or highly subsidized, ITNs encourages their use of health services.|
|Storage||Bulky ITNs can sometimes pose a problem if adequate space is not available in health facilities (during direct distribution).|
|Staff movement||Turnover may remove personnel trained in management of the ITN distribution and leave gaps in knowledge of ITN distribution and reporting.|
|Stock-outs||Even temporary stock disruptions can frustrate beneficiaries and possibly decrease the use of routine health services.Continued support and follow-up to ensure continuous supply are costly but essential.|
|Overburdening the health system||Health staff members are often overworked, underpaid, and working in difficult circumstances. The addition of a new project to existing responsibilities, particularly the reporting requirements, may be seen as more of a burden than a benefit, and staff motivation to implement can suffer if adequate measures are not taken to ensure motivation.|
|Monitoring and evaluation||Health management information systems (HMIS) are a challenge in many countries. To respond to donor requirements, NMCPs and partners have had to, at times, collect information in parallel with existing HMIS or provide additional support to the HMIS in order to secure complete, correct, and timely reporting. As routine delivery of ITNs requires sustained reporting and timely periodic data management throughout the year, robust reporting and data management systems often need to be put in place and monitored, which adds to the health systems burden.|
|Supervision||NMCPs, as technical divisions of their MOH, often do not have line authority within the health system pyramid. Reproductive health and maternal and child health divisions are more likely to be in charge of supervision of ANC and child health services, making coordination among these MOH divisions, and a clear division of responsibilities, a priority from the outset of program planning.|