title: Rapid scaling up of insecticide-treated bed net coverage in Africa and its relationship with development assistance for health: a systematic synthesis of supply, distribution, and household survey data.
abstract: BACKGROUND
  Development assistance for health (DAH) targeted at malaria has risen exponentially over the last 10 years, with a large fraction of these resources directed toward the distribution of insecticide-treated bed nets (ITNs). Identifying countries that have been successful in scaling up ITN coverage and understanding the role of DAH is critical for making progress in countries where coverage remains low. Sparse and inconsistent sources of data have prevented robust estimates of the coverage of ITNs over time.
  
  
  RESULTS
  We combined data from manufacturer reports of ITN deliveries to countries, National Malaria Control Program (NMCP) reports of ITNs distributed to health facilities and operational partners, and household survey data using Bayesian inference on a deterministic compartmental model of ITN distribution. For 44 countries in Africa, we calculated (1) ITN ownership coverage, defined as the proportion of households that own at least one ITN, and (2) ITN use in children under 5 coverage, defined as the proportion of children under the age of 5 years who slept under an ITN. Using regression, we examined the relationship between cumulative DAH targeted at malaria between 2000 and 2008 and the change in national-level ITN coverage over the same time period. In 1999, assuming that all ITNs are owned and used in populations at risk of malaria, mean coverage of ITN ownership and use in children under 5 among populations at risk of malaria were 2.2% and 1.5%, respectively, and were uniformly low across all 44 countries. In 2003, coverage of ITN ownership and use in children under 5 was 5.1% (95% uncertainty interval 4.6% to 5.7%) and 3.7% (2.9% to 4.9%); in 2006 it was 17.5% (16.4% to 18.8%) and 12.9% (10.8% to 15.4%); and by 2008 it was 32.8% (31.4% to 34.4%) and 26.6% (22.3% to 30.9%), respectively. In 2008, four countries had ITN ownership coverage of 80% or greater; six countries were between 60% and 80%; nine countries were between 40% and 60%; 12 countries were between 20% and 40%; and 13 countries had coverage below 20%. Excluding four outlier countries, each US$1 per capita in malaria DAH was associated with a significant increase in ITN household coverage and ITN use in children under 5 coverage of 5.3 percentage points (3.7 to 6.9) and 4.6 percentage points (2.5 to 6.7), respectively.
  
  
  CONCLUSIONS
  Rapid increases in ITN coverage have occurred in some of the poorest countries, but coverage remains low in large populations at risk. DAH targeted at malaria can lead to improvements in ITN coverage; inadequate financing may be a reason for lack of progress in some countries. Please see later in the article for the Editors' Summary.
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America.
authors.forename: Abraham D
authors.initials: AD
authors.lastname: Flaxman
authors.forename: Nancy
authors.initials: N
authors.lastname: Fullman
authors.forename: Mac W
authors.initials: MW
authors.lastname: Otten
authors.forename: Manoj
authors.initials: M
authors.lastname: Menon
authors.forename: Richard E
authors.initials: RE
authors.lastname: Cibulskis
authors.forename: Marie
authors.initials: M
authors.lastname: Ng
authors.forename: Christopher J L
authors.initials: CJ
authors.lastname: Murray
authors.forename: Stephen S
authors.initials: SS
authors.lastname: Lim
mesh_terms: D000349:Africa / Q000453:epidemiology; D002675:Child, Preschool; D003625:Data Collection / Q000379:methods; D003695:Delivery of Health Care / Q000191:economics / Q000639:trends*; D005191:Family Characteristics; D006301:Health Services Needs and Demand / Q000191:economics / Q000639:trends; D006801:Humans; D007223:Infant; D057148:Insecticide-Treated Bednets; D008288:Malaria / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control*; D009032:Mosquito Control / Q000191:economics / Q000295:instrumentation / Q000639:trends*
references.citation: Trop Med Int Health. 2003 Aug;8(8):693-703
references.pmid: 12869090
references.citation: JAMA. 2007 May 23;297(20):2241-50
references.pmid: 17519414
references.citation: Public Health. 2007 Feb;121(2):122-9
references.pmid: 17217972
references.citation: Am J Trop Med Hyg. 2006 Jan;74(1):12-6
references.pmid: 16407339
references.citation: Trop Med Int Health. 2005 Nov;10(11):1141-50
references.pmid: 16262739
references.citation: Bull Soc Pathol Exot. 2010 May;103(2):123-9
references.pmid: 20635461
references.citation: Lancet. 2009 Jan 3;373(9657):58-67
references.pmid: 19019422
references.citation: PLoS Med. 2007 Aug;4(8):e255
references.pmid: 17713981
references.citation: Am J Trop Med Hyg. 2008 Jul;79(1):45-52
references.pmid: 18606763
references.citation: Lancet. 2009 Jun 20;373(9681):2113-24
references.pmid: 19541038
references.citation: Lancet. 2007 Sep 22;370(9592):1035-9
references.pmid: 17889242
references.citation: J Stat Softw. 2010 Jul;35(4):1-81
references.pmid: 21603108
references.citation: PLoS One. 2009 Dec 22;4(12):e8409
references.pmid: 20027289
references.citation: Cochrane Database Syst Rev. 2004;(2):CD000363
references.pmid: 15106149
references.citation: Malar J. 2006 Apr 24;5:33
references.pmid: 16635265
references.citation: PLoS Med. 2008 Jul 22;5(7):e142
references.pmid: 18651785
references.citation: Am J Trop Med Hyg. 2009 Jan;80(1):133-40
references.pmid: 19141851
references.citation: Am J Trop Med Hyg. 2009 Feb;80(2):209-14
references.pmid: 19190215
references.citation: Sex Transm Infect. 2008 Aug;84 Suppl 1:i11-i16
references.pmid: 18647860
references.citation: BMJ. 2009 Jul 02;339:b2434
references.pmid: 19574316
references.citation: Malar J. 2008 Mar 20;7:49
references.pmid: 18355408
references.citation: Lancet. 2008 Dec 13;372(9655):2031-46
references.pmid: 19070738
references.citation: Lancet. 2001 Apr 21;357(9264):1241-7
references.pmid: 11418148
references.citation: Malar J. 2006 May 05;5:36
references.pmid: 16677379
references.citation: Malar J. 2005 Jul 22;4:34
references.pmid: 16042780