1. LLIN Continuous distribution through community channels in Nigeria Godwin Aidenagbon - MAPS Emmanuel Obi – NetWorks 16 October, 2013

2. Presentation Outline Background/overview Conceptual basis for a community distribution system Designs of community-drive continuous LLIN distribution Procedures for delivery of LLINs through community channels e.g CDDs Issues to consider in scale up Future plans

3. Background/Overview The objective of continuous LLIN distribution is to sustain universal coverage (UC) The family typically determines how LLINs will be utilized within the household The key is to make sure there are sufficient LLINs to cover all household members at any given time Multiple channels will be required to sustain UC; one type of channel is the use of community drug distributors NetCALC can be used to project effectiveness of various channels, based on data and tailored to states’ situation. Different states will have different strategies based on state context

4. Conceptual basis for a community LLIN distribution system There is overwhelming evidence that the communal life in Nigerian society engenders a strong spirit of volunteerism. Volunteers are selected by the community and they are willing to sacrifice their time and resources to promote the good of the community. Volunteers play in key role in community development and several health programs in the past have used community structures to promote access to key interventions. Examples in Nigeria include the Oncho program among others. Volunteers work for the good of the community and are not directly remunerated for the services provided. There is community recognition for the services provided by community volunteers to the community.

5. Conceptual basis for a community LLIN distribution system contd..  Families are proactive and initiate the process of getting LLINs; this may make them more likely to use them (pull strategy)  Continuous distributions provide multiple opportunities per year even if one of them is missed for some reason  Allows a phased-in approach to first fill gaps left by the campaign and then attend to replacements  Existing community structures to increase awareness about the availability of nets through the CDD-ANC system and generate demand

6. Monthly/Quarterly Receives LLIN at 1 st ANC visit HHCDDHub State, LGA Request Verify, give LLIN Slip Deliver PW Receives Mother’s card at ANC 1. Nasarawa Design: ANC + CDD

7. 2. Zamfara design: ANC + CDD/WDCs (modified) Community component

8. Procedure for delivery of LLINs through community channels There are 5 CDDs in each of the wards of the state (4 wards per LGA). The CDDs have been trained on how to support households to access LLINs. Based on information provided by LGA RBM & LIHT to CDDs and WDCs, a request for a net is initiated by a household member. The request shall be communicated by the household member to a CDD, who will proceed to conduct a need assessment for the household. If the CDD is satisfied that the eligibility criteria has been met, he/she will issues net SLIPs based on gap to the potential beneficiary. CDD keeps assessment records/counterfoil of SLIP

9. Procedure for delivery of LLINs through community channels contd… The potential beneficiary presents SLIP(s) at designated facility and retains 1 (for sake of verification) Health worker keeps 1 Slip and issues 1 net to beneficiary. Beneficiary takes net home and hangs for use. Health worker files redeemed slip Health worker enters data from the slip into the facility register. He regularly reconciles SLIP with register for accountability purposes. LGA RBM FP collates data from all facilities and reconciles data with LIHT (LGA Integrated Health Team) CDD pays visit to the household to ensure hanging and use of the net as well as addressing issues relating to net use.

10. Issues to consider in scale up  Eligibility criteria o issuance of nets according to identified gap  Logistics o continuos availability of LLINs and materials in sufficient quantities  Consideration for motivation o WDCs ensure community recognition, including job aids o some transport allowance when then attend meetings  Acceptability of the strategy o Sensitization and involvement will be crucial at all levels - stakeholders/community mobilization  Strong monitoring and supervision component o Quarterly intensive monitoring and supportive supervisory visits o Avoiding high attrition rates for CDDs, for good performance o In-process monitoring and primary output data

11. Community mobilization for CDD-based strategy Community Ward DC CDD HF / Store Ward informs HH HH can complain Select CDD HH can complain HH participate in selection HH requests CDD assess HH receives net BCC Sensitize

12. Taking community distribution to scale in MAPS states Lessons learnt from the Nasarawa CDD system have carefully guided the process of roll out of community distribution of LLINs in Zamfara and Ebonyi state. CDD selection is now tilted in favour of volunteers who have an existing vocation. This will reduce CDD attrition. CDD visibility is enhanced with branded kits. Consistency in procedure(s) for service delivery and messaging is enhanced by a CDD job aid. CDD have also been trained to carry out community mobilization activities as their community activity

13. Taking community distribution to scale in MAPS states contd… CDDs have been integrated into MAPS existing community BCC structures. This has provided additional support to ease the work of the CDDs –Ward development committees –Community volunteers carrying out other malaria control tasks beyond LLINs –Community mobilizers –MAPS CBO sub grantees Improving data management and coordination by having Monthly State and LGA RBM-CDI meeting Quarterly State and LGA CDD-based review meeting with key stakeholders at both levels

14. Plans in FY14  Continue implementing and monitoring Nasarawa and Zamfara programs  Nasarawa state program will be evaluated in 2014 and results about the effectiveness of CDD will be available in August 2014  Evaluate different types of continuous distribution approaches. (Results available in 2014)  http://www.k4health.org/toolkits/continuous- distribution-malaria => contains resources for continuous distribution http://www.k4health.org/toolkits/continuous- distribution-malaria