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Publication date: 
August 17, 2010


Bed net distribution and use has expanded rapidly across Africa, especially in countries that have received significant health aid for malaria prevention efforts, research shows. The study, 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, makes use of an innovative statistical tool that could have broader application in other public health settings. The study was conducted in collaboration with the World Health Organization and the US Centers for Disease Control and Prevention.

Research findings

In 44 countries in Africa with large populations at risk for malaria, bed net ownership has increased from an average of 2.2% of the at-risk population in 1999 to 32.8% in 2008. Use of bed nets by children under age 5 was 1.5% on average in 1999 and had increased to 26.6% in 2008.

Both ownership and use were uniformly low among the 44 countries in 1999. Since then, rapid increases in bed net coverage have occurred in some of the poorest countries, especially in the latter part of the last decade, with some countries that started with almost no nets in homes able to deliver bed nets to 60% of homes at risk in that time.

By 2008, four countries had ownership coverage of 80% or more of the at-risk population; six countries were between 60% and 80%; nine were between 40% and 60%; 12 were between 20% and 40%; and 13 were below 20%.

Countries that received the most health aid for malaria programs had the fastest scale-up of bed net distribution. Excluding four outlier countries, each US$1 per capita in health aid spent on malaria efforts was associated with a rise in household bed net ownership and use in children under 5 of 5.3 percentage points and 4.6 percentage points, respectively.

Analytical approach

IHME and its collaborators took a “stock and flow model,” which is more commonly used by pharmaceutical firms to track their products, and developed it as a way to track bed nets, even in countries where data are poor. The method uses household survey data, manufacturer reports of bed net deliveries to countries, and National Malaria Control Program reports. The researchers believe the model has broad application to help study the scale-up of other global health interventions, including vaccines and medications.

Research objective

This bed net study is part of ongoing work by IHME to calculate the impact of malaria in terms of death and injury and to measure the impact of interventions to prevent and treat malaria. In addition to bed nets, IHME has studied other interventions, including vaccines and skilled birth care, to measure their scope and impact, with the goal of providing the most complete and accurate health data on key health indicators worldwide.

Recommendations for future work

Case studies of countries where bed net scale-up has been successful could help inform policies to increase coverage in other countries. Previous studies have shown how countries such as Eritrea, Kenya, Sao Tome and Principe, Tanzania, and Zambia have used free mass distribution, social marketing, vouchers, and other means to scale up bed net coverage. Future case studies could include Ethiopia, Equatorial Guinea, Liberia, Mali, and Sierra Leone.

Of particular interest is how some countries with low levels of coverage of other key interventions have been able to rapidly distribute bed nets. Niger and Ethiopia have expanded bed net ownership quickly, while the use of skilled birth attendance for women during delivery has remained low. Case studies in these settings could contrast the methods used for these different interventions.


Flaxman AD, Fullman N, Otten MW Jr., Menon M, Cibulskis RE, Ng M, Murray CJL, Lim SS. 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. PLoS Medicine. 2010 August 17; 7(8): e1000328.