Strategies for delivering insecticide-treated nets at scale for malaria control: a systematic review

Bull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771 Systematic reviews 672 Strategies for delivering insecticide-treated nets at scale for malaria control: a systematic review Barbara A Willey,a Lucy Smith Paintain,b Lindsay Mangham,a Josip Carc & Joanna Armstrong Schellenbergb Introduction Malaria continues to represent a major public health problem in areas of endemicity, with an estimated 225 million cases worldwide in 2009.1 The 2015 goals of the World Health Or- ganization’s (WHO’s) Roll Back Malaria Partnership are to reduce global malaria cases by 75% from 2000 levels and to reduce malaria deaths to near zero through universal coverage by effective prevention and treatment interventions.1 Among other preventive interventions, WHO recommends the use of insecticide-treated nets (ITNs), particularly long-lasting insecticidal nets, which have been shown to be cost-effective,2–4 to reduce malaria episodes among children < 5 years of age (hereafter, “children under 5”) by approximately 50% and all-cause mortality by 17%.5,6 Universal coverage with ITNs is defined as use by > 80% of individuals in populations at risk.6 WHO recommends supplying ITNs without charge or with a high subsidy and using a combination of periodic mass cam- paigns and routine delivery channels to deliver ITNs at scale.6 Other strategies include supporting the existing commercial sector and distributing vouchers exchangeable for partially subsidized ITNs through retailers.7 In response to the Roll Back Malaria Partnership’s targets for universal coverage, considerable efforts have been made recently to scale up ITN delivery. However, there is still low coverage in many countries and a need to understand the les- sons learnt from experiences of scaling up ITN delivery. We therefore conducted a systematic review to synthesize recent evidence on the delivery of ITNs (including long-lasting insec- ticidal nets) at scale in malaria-endemic areas by documenting and characterizing the strategies for delivering ITNs at scale (at the district level or higher); summarizing ITN ownership among households and ITN use among children under 5, stratified by measures of equity when possible; summarizing the reported cost or cost-effectiveness of different strategies; and synthesizing information on reported factors influencing delivery of ITNs at scale. Methods A systematic review was conducted to identify studies that reported on the delivery of ITNs (including long-lasting in- secticidal nets) at scale. The findings reported here form part of a larger systematic review on the scale-up of WHO-recom- mended malaria control interventions.8 We used a definition of “scaling up” that characterized this activity as the expansion of a health intervention beyond the initial geographical area or population group covered.9,10 We considered “at scale” to be ITN delivery in at least one district or the equivalent low- est level of health service administration in a given country. Search strategy Medline (Ovid), EMBASE, CAB Abstracts, Global Health and Africa Wide databases were searched using subject heading classification terms and free-text words. The following catego- ries were combined using the AND Boolean logic operator: malaria terms, ITN and long-lasting insecticidal net terms and scaling-up terms (Box 1, available at: http://www.who.int/ bulletin/volumes/90/9/11-094771). Filters were used to limit the search to humans and to publication dates from January Objective To synthesize findings from recent studies of strategies to deliver insecticide-treated nets (ITNs) at scale in malaria-endemic areas. Methods Databases were searched for studies published between January 2000 and December 2010 in which: subjects resided in areas with endemicity for Plasmodium falciparum and Plasmodium vivax malaria; ITN delivery at scale was evaluated; ITN ownership among households, receipt by pregnant women and/or use among children aged < 5 years was evaluated; and the study design was an individual or cluster-randomized controlled design, nonrandomized, quasi-experimental, before-and-after, interrupted time series or cross-sectional without temporal or geographical controls. Papers describing qualitative studies, case studies, process evaluations and cost-effectiveness studies linked to an eligible paper were also included. Study quality was assessed using the Cochrane risk of bias checklist and GRADE criteria. Important influences on scaling up were identified and assessed across delivery strategies. Findings A total of 32 papers describing 20 African studies were reviewed. Many delivery strategies involved health sectors and retail outlets (partial subsidy), antenatal care clinics (full subsidy) and campaigns (full subsidy). Strategies achieving high ownership among households and use among children < 5 delivered ITNs free through campaigns. Costs were largely comparable across strategies; ITNs were the main cost. Cost-effectiveness estimates were most sensitive to the assumed net lifespan and leakage. Common barriers to delivery included cost, stock-outs and poor logistics. Common facilitators were staff training and supervision, cooperation across departments or ministries and stakeholder involvement. Conclusion There is a broad taxonomy of strategies for delivering ITNs at scale. a Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, England. b Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, England. c School of Public Health, Imperial College London, London, England. Correspondence to Barbara Willey (e-mail: barbara.willey@lshtm.ac.uk). (Submitted: 24 August 2011 – Revised version received: 31 January 2012 – Accepted: 2 February 2012 – Published online: 6 July 2012 ) S stematic reviews Bull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771 673 Systematic reviews Insecticide-treated nets for malaria controlBarbara A Willey et al. 2000 to December 2010. Relevant papers from the grey literature were identified by searching Eldis and WHOLIS data- bases and Roll Back Malaria, Malaria Consortium, Africa Malaria Network Trust, and The Global Fund to Fight AIDS, Tuberculosis and Malaria web sites. Citation data for identified papers were exported to EndNote (Thomson Reuters, Carlsbad, USA), where dupli- cates were removed. Eligibility criteria Screening was a two-stage process. First, two authors (BW and LSP) inde- pendently screened titles and abstracts to determine which papers should un- dergo full-text assessment for eligibility. Retained papers underwent full-text review (performed independently by BW and LSP) to determine whether they described studies that satisfied the following criteria: subjects resided in areas where Plasmodium falciparum and Plasmodium vivax are endemic; ITN delivery at scale was evaluated; ITN ownership among households, receipt by pregnant women and/or use among children under 5 was evaluated; and an individual or cluster-randomized con- trolled design, a nonrandomized design, a quasi-experimental design, a before- and-after design, an interrupted time series design or a cross-sectional design without temporal or geographical con- trols was used.11–13 Papers meeting these criteria were termed “index papers”. In addition to documenting and character- izing the strategies for delivering ITNs at scale and summarizing ITN ownership among households and ITN use among children under 5, this review also aimed to summarize the reported cost or cost- effectiveness of different strategies and to synthesize information on reported factors influencing delivery of ITNs at scale. As such, we also included papers that described qualitative studies, case studies, process evaluations and cost- effectiveness studies that were linked to an index paper. The reference lists from eligible pa- pers were hand-searched for additional relevant citations. All data relevant to the review were extracted from final included papers into an Access database (Microsoft, Redmond, United States of America). Analysis The first objective was to document and characterize the strategies for de- livering ITNs at scale and was guided by a framework adapted from Kilian et al.14 Strategies were characterized by target population, implementation scale, implementer type, user cost and implementation duration (Fig. 1). The effectiveness of ITN delivery strategies was not compared using meta- analysis because study designs were too variable.15 Rather, narrative synthesis with a Best Evidence Synthesis approach was used to summarize findings and compare results across the different delivery strategies.16,17 The extent to which ITN ownership or use changed over time and whether such changes were attributable to the de- livery strategy were assessed according to study quality. The quality of studies with a randomized or nonrandomized control group and of those using an interrupted time-series design was as- sessed using the Cochrane risk of bias checklist15 and Grading of Recommen- dations Assessment, Development and Evaluation (GRADE) criteria.18 All reported costs were adjusted for inflation by two authors (LSP and LM) and are presented as 2010 United States dollars (US$) using the consumer price indices available from the International Monetary Fund.19 When possible, costs are reported separately as financial (i.e. monetary) costs or economic costs (in- cluding opportunity costs and costs of donated goods and services). Content analysis and narrative syn- thesis were used to identify important influences on delivering ITNs at scale and themes were assessed across the different ITN delivery strategies.16,17 Results Fig. 2 details the literature search and screening process, performed according to guidelines of the Preferred Reporting Items for Systematic Reviews and Meta- Analyses (PRISMA) Group.20 We includ- ed 32 papers that described 20 studies from 12 African nations (Burkina Faso, Eritrea, Ghana, Kenya, Madagascar, Malawi, Niger, Nigeria, Togo, Uganda, the United Republic of Tanzania and Zambia) and one partially autonomous region (Zanzibar). Six studies were implemented on a national level, two on a regional scale and 12 at the district level (of which three took place in only one district). Fourteen studies delivered ITNs only to children under 5 and/or pregnant women (Table 1 and Table 2, both available at: http://www.who.int/ bulletin/volumes/90/9/11-094771). Strategies for delivering ITNs at scale Fig. 3 summarizes the characteristics of the strategies used to deliver ITNs at scale using the categories presented by Kilian et al.14 Routine health services, retailers and community-based agents were used to deliver ITNs on a continu- ous basis. Time-limited strategies either integrated the distribution of ITNs with a public health campaign or delivered ITNs through a stand-alone campaign. Most continuous strategies partially sub- Fig. 1. Characteristics of strategies for delivering insecticide-treated nets at scale At-risk population National Subnational region District Children aged < 5 years Routine health services Stand-alone campaign Community Retail Campaign integrated with public health campaign Private sector Pregnant women At cost Coverage Equity Cost Partial subsidy Time- limited Continuous Target population Implementation scale Implementer User cost Implementation duration Output Full subsidy (free) Source: Adapted from Kilian et al.14 Bull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771674 Systematic reviews Insecticide-treated nets for malaria control Barbara A Willey et al. sidized the delivery of ITNs, whereas all time-limited strategies fully subsidized delivery of ITNs. Most strategies that used routine health services targeted pregnant women or children under 5. All strategies involving time-limited integrated campaigns and stand-alone campaigns targeted children under 5, whereas strategies using retailers and community-based delivery provided ITNs to the general population. Seven studies used a combination of strategies. Studies with high ITN ownership or use Eighteen studies reported ITN owner- ship among households and/or ITN use among children under 5 (Table 2). ITN ownership among households ranged from 1.3% to 94% and ITN use among children under 5, which is typically lower than the prevalence of household ITN ownership, ranged from 12% to 94%. Ten studies reported a high preva- lence of ITN ownership or use during at least one survey conducted after ini- tiation of the ITN delivery strategy. Six reported ownership by > 60% of househo lds,25,42–44,47,48,50,51 two reported owner- ship by > 80% of households29,30,49 and two reported use by ≥ 87% of children under 5.27,41 Of the six studies reporting owner- ship by > 60% of households, four used an uncontrolled cross-sectional survey design, surveying 300–3000 households 1–3 years after delivery began.25,44,50,51 The other two used a before-and-after design in which approximately 2500 households were surveyed before and one year after ITN delivery during cam- paigns integrated with measles vaccina- tion.42,43,47,48 During the 1–2-year period between baseline and endline surveys, ITN ownership among households in- creased from 24.5% to 79% in one study and from < 1% to 55–70% in the other. The two studies reporting ITN own- ership by > 80% of households were un- controlled cross-sectional surveys. A total of 475 households in Ghana29,30 and 2074 households in Zambia49 were surveyed five months and six months, respectively, after ITN delivery campaigns. ITN ownership in Ghana was 90%, whereas ownership in Zambia was 88% in rural areas and 82% in urban areas. In Ghana, a follow-up survey conducted 38 months after the initial survey revealed that ownership among households had decreased by 18%, to 74%. Both studies reporting a high prevalence of ITN use among children under 5 also had an uncontrolled cross-sectional design. A total of 378 households in the Adjumani district of Uganda were surveyed 5–7 months after distribution of partially subsidized ITNs to pregnant women through antenatal care clinics27 and 264 households in the North A district of Zanzibar were surveyed 5 months after ITN delivery during a stand-alone ITN campaign.41 Responses revealed use by 94% of chil- dren under 5 in households surveyed in the Adjumani district and by 87% of children under 5 in the North A district. All 10 studies that reported a high prevalence of ITN ownership or use provided fully subsidized ITNs through at least one component of their delivery strategy (Fig. 3 and Table 2). Seven studies provided fully subsidized ITNs through a stand-alone campaign only (in one41) or through an integrated cam- paign only (in six42–44,47–51). One study considered the continuous delivery of free ITNs through antenatal clinics.25 Two studies evaluated combined strat- egies.27,29,30 In one, ITNs were delivered to pregnant women through antenatal clinics on a continuous basis by use of a partially subsidized voucher system and to children under 5 through a campaign integrated with measles vaccination, at full subsidy.29,30 In the other, ITNs were delivered under a full subsidy to preg- nant women through antenatal clinics on a continuous basis and for free to children under 5 during a stand-alone campaign on a time-limited basis.27 Equity of ITN ownership and use Thirteen studies reported coverage stratified according to socioeconomic Fig. 2. Flow of selection process for inclusion of studies of strategies for scaling up delivery of insecticide-treated nets (ITNs) for malaria control in areas with endemicity for Plasmodium falciparum and Plasmodium vivax malaria 4 articles were identified from hand-searching reference lists 478 records were excluded 63 full-text articles were excluded 14 were not included because of narrowed focus of review on ITNs and LLINs 3 evaluated IVC4 evaluated multiple interventions 4 evaluated IPTp 3 evaluated ACT 26 did not address scale-up 21 evaluated strategies in areas smaller than district level 9 did not include primary data 3 did not evaluate relevant malaria intervention 2 discussed policy change, not scale-up 2 were excluded for other reasons 1295 records were identified through search of 5 medical and public health databases 29 additional records were identified through search of 2 grey literature databases and web sites 583 titles and abstracts were screened 105 full-text articles were assessed for eligibility 46 articles met inclusion criteria 32 articles focussed on ITNs and LLINs 32 articles (20 studies) were included for narrative synthesis 583 records remained after duplicates were removed ACT, artemisinin combination treatment; IPTp, intermittent preventive treatment in pregnant women; IVC, integrated vector control; LLIN, long-lasting insecticidal net. Bull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771 675 Systematic reviews Insecticide-treated nets for malaria controlBarbara A Willey et al. status as a measure of equity (Table 2). One study evaluated equity on the basis of urban and rural residence and twelve studies evaluated it on the basis of a household asset index. Of the latter studies, three reported a concentration index and nine reported an equity ratio. A concentration index ranges from −1 to 1, with a value of 0 indicating equi- table distribution and values > 0 indicat- ing inequitable distribution benefiting the least poor group. An equity ratio measures the equity of distribution in the poorest quintile relative to that in the least poor quintile, with a value of 1 indicating equitable distribution and values between 0 and 1 indicating inequitable distribution benefiting the least poor group. The study that evaluated equity in terms of urban and rural residence was based on data from a national survey performed after partially subsidized delivery of ITNs to pregnant women and children under five at health centres.28 The survey found greater use among children under 5 in urban areas, com- pared with those in rural areas (51% versus 17%). Three studies presented the concen- tration index of ITN ownership among households or ITN use among children under 5. The concentration index in each revealed higher ITN ownership or use among the least poor groups. One study had a quasi-experimental design and evaluated continuous delivery of partially subsidized ITNs through health care facilities.21 The other two used a cross-sectional design to assess the fully subsidized delivery of ITNs during a stand-alone campaign27 or dur- ing a campaign integrated with measles vaccination.46 Nine studies presented the equity ratio, or sufficient data for its calculation, of ITN ownership among households or ITN use among children under 5 (Fig. 3). The highest ownership was reported in the poorest quintile in four campaigns that integrated the delivery of free ITNs with measles vaccination. Two of the four used a cross-sectional design to evaluate strategies at either the national or district levels.44,49 The other two used a before-and-after design and also reviewed delivery at the district or national levels.42,43,47,48 The change in equity index was available only for Fig. 3. Equity ratios and prevalence of household ownership of insecticide-treated nets (ITNs) and use among children aged < 5 years in areas with endemicity for Plasmodium falciparum and Plasmodium vivax malaria, by delivery strategya,3,21–25,27–30,32–35,39–51 Ownership Equity ratio, ownership Equity ratio, useUse Eq ui ty ra tio b 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Bu rkin a F aso 22- 24 Erit ea 25 Ug and a: A dju ma ni 27 Zam bia : Ch ipa ta, Lun daz i, C ham a, C had iza , Pe tau ka 21 Un ited Re pu blic of Tan zan ia: nat ion al 32– 35 Un ited Re pu blic of Tan zan ia: Zan zib ar, No rth A 41 Un ited Re pu blic of Tan zan ia: Zan zib ar, Mi che we ni 41 Ken ya: Kw ale , Bo nd o, G rea ter Kis ii, M aku eni 42, 43 Zam bia : ur ban (K ala lus hi) 49 Zam bia : ru ral (Ch ilub i, K apu ta, Ma mb we , N yim ba) 49 Un ited Re pu blic of Tan zan ia: Lin di 45 Ken ya (35 dis tric ts) 28 Gh ana : La wr a2 9,3 0 Ma law i3, 39, 40 Ug and a: A dju ma ni 27 Ug and a: J inja 27 Ma dag asc ar 44 Un ited Re pu blic of Tan zan ia: Ru fiji 46 Tog o: T on e4 7,4 8 Tog o: O go u4 7,4 8 Nig er 50 Nig eria 51 Tog o: Y oto 47, 48 Gh ana : La wr a2 9,3 0 IT N ow ne rs hi p or u se , % 100 90 80 70 60 50 40 30 20 10 0 Full subsidy (health facilities, community-based) Partial subsidy (health facilities, community-based, retail) Stand-alone campaign Measlesc Poliod LFe Continuous duration Time-limited duration, full subsidy a Studies may appear in more than one category if multiple strategies were used to deliver ITNs at scale or if strategies changed over time. b Value of 1 indicated equitable distribution, marked on figure by a red dashed line. Ratios > 1 suggest that the poorest quintiles were favoured. c Campaign integrated with measles vaccination campaign. d Campaign integrated with polio vaccination campaign. e Campaign integrated with mass drug administration for lymphatic filariasis (LF) campaign. Bull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771676 Systematic reviews Insecticide-treated nets for malaria control Barbara A Willey et al. one of the before-and-after studies and involved a decrease from 1.2 to 1.1.42,43 ITN use was similar across quintiles in two studies, both of which used an uncontrolled cross-sectional survey de- sign of delivery at the district level. The strategy evaluated in one delivered ITNs during a stand-alone campaign.41 The other investigated a combined strategy involving delivery of fully subsidized ITNs to children under 5 through a campaign integrated with measles vac- cination and partially subsidized ITNs to pregnant women through antenatal clinics.29,30 In five studies, ITN ownership or use was higher in the least poor quintile. Three studies evaluated the delivery of free ITNs to children under 5 through a campaign integrated with polio or mea- sles vaccination in Niger, in Lindi region of the United Republic of Tanzania, and four rural districts of Zambia (Chilubi, Kaputa, Mambwe and Nyimba).45,49,50 In the fourth study, the delivery of partially subsidized ITNs to pregnant women via antenatal care clinics in the United Republic of Tanzania was examined.32–35 The fifth study reviewed a stand-alone ITN campaign involving distribution of fully subsidized nets to children under 5 in the Micheweni district of Zanzibar.41 Study quality Table 2 shows the variety of study designs used to assess ITN delivery strategies. Of the 18 studies reporting data on ITN ownership among house- holds and ITN use among children under 5, the study design in two (a cluster-randomized controlled trial22–24 and a quasi-experimental study without randomization21) involved comparison areas, and the study design in four involved a temporal comparison. Two of the studies with a temporal compari- son evaluated time-limited delivery of fully subsidized ITNs42,43,47,48 and two analysed continuous delivery of partially subsidized ITNs.3,36,38–40 As such, the interpretation of ITN ownership among households and ITN use among children under 5 between survey years varies by study design and delivery strategy. Only the cluster-randomized con- trolled trial directly compared different delivery strategies.22–24 One strategy involved subsidized sale, promoted by social marketing, of ITNs to the gen- eral population plus free distribution of long-lasting insecticidal nets to pregnant women at antenatal care clinics. The other strategy involved only subsidized sale, promoted by social marketing, of ITNs to the general population through retailers. Ownership of ITNs was 35% in the dual-intervention arm and 23% in the retail-only arm (P < 0.001). Although the risk of bias was low in this study, the quality of the evidence was downgraded from high to moderate on the basis of the GRADE criteria because it was un- clear whether analyses adjusted for the clustered design and because no relative measure of effect was provided. One study described the delivery of partially subsidized ITNs at the district level through sales by health facil- ity staff.21 ITN ownership was 14% in three intervention districts, compared with 1.3% in two comparison districts (P < 0.001). The risk of bias in this study was moderate principally because of the lack of randomization. The quality of evidence was very low on the basis of the GRADE criteria because there were im- portant differences between intervention and comparison areas at baseline (e.g. socioeconomic status) that were not ad- justed for in the analysis and because no relative measure of effect was provided. In nonrandomized studies, identi- fication of the channel through which the ITN is delivered (i.e. antenatal clinics or retail shops) may help deter- mine whether the change in coverage achieved can be allocated to the delivery strategy.12 Studies in three countries did not stratify ITN ownership by delivery channel.3,36–40,47,48 However, elsewhere, a decline in the proportions of unsub- sidized ITNs sourced from retailers and partially subsidized ITNs sourced from maternal and child health clinics was seen among children under 5.42,43 Both decreases occurred after initiation of an integrated campaign in 2006 to distribute fully subsidized ITNs, with the campaign contributing almost half of the ITNs used by children under 5 surveyed during 2006–2007. Costs Ten studies reported on the cost or cost- effectiveness of ITNs (Table 3). Of these, seven described only cost per ITN de- livered or cost per treated-net–year. The remaining three were cost-effectiveness studies that also presented cost per death or per disability-adjusted life year averted. All except one of the economic evaluation studies conducted sensitiv- ity analyses around the major cost and outcome parameters. Four studies investigated the cost of delivering free ITNs through antenatal care clinics, with three at the district level and one at the national level. In the district-level studies, financial costs ranged from US$ 8.20 to US$ 10.54 per ITN delivered22,26,27 and economic costs ranged from US$ 5.47 to US$ 5.89 per ITN delivered.22,27 The study at the na- tional scale reported an economic cost of US$ 10.77 per ITN delivered.25,35 Of the four studies that evalu- ated the delivery cost of partially subsi- dized ITNs, three investigated delivery through the retail sector and one investigated voucher use. Studies of retail-based delivery reported financial costs of US$ 5.47 and US$ 11.16 per ITN delivered in Burkina Faso and Malawi, respectively, and of US$ 12.57 and US$ 18.72 per treated-net–year in the United Republic of Tanzania and Malawi, respectively.3,22,36 The studies in Burkina Faso and the United Republic of Tanzania were at the district level and the study in Malawi was at the national level; the length of protection afforded by ITNs in calculations of cost per ITN delivered was assumed to be 12 months in Burkina Faso and 6 months in Ma- lawi. The fourth study investigated the Tanzanian National Voucher Scheme and found economic costs of US$ 10.77 per ITN delivered and US$ 6.02 per treated-net–year, with the latter calcu- lation assuming 12-month protection from a treated net.35 The four studies that evaluated fully subsidized campaigns found financial costs per ITN delivered of US$ 3.71 to US$ 11.79 for those integrated with vac- cination campaigns30,45,49 and US$ 9.48 for a stand-alone campaign.27 The stand- alone campaign considered in one of the studies had an economic cost per ITN delivered of US$ 4.76.27 Three studies presented some mea- sure of health impact. The economic cost per child death averted was US$ 1242 for a national voucher scheme35 and US$ 2924 for a retail sector programme involving partially subsidized delivery.36 The economic cost per disability- adjusted life year averted was similar, at US$ 100 and US$ 107.25,36 Cost or cost-effectiveness estimates were most sensitive to the assumed ITN lifespan (i.e. physical viability and duration of insecticide protection) and the proportion of ITNs actually used (leakage). The main cost associated with ITN delivery programmes was the ITNs Bull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771 677 Systematic reviews Insecticide-treated nets for malaria controlBarbara A Willey et al. Ta bl e 3. Ch ar ac te ris tic s a ss oc ia te d w ith fi na nc ia l a nd e co no m ic co st s o f i ns ec tic id e- tr ea te d ne ts (I TN s) in a re as w ith e nd em ici ty fo r P la sm od iu m fa lci pa ru m a nd P la sm od iu m vi va x m al ar ia , b y d el iv er y st ra te gy a De liv er y s tr at eg y Co un tr y, sc al e Pe rs pe ct iv e, in te rv al Co st Ne t l ife sp an c Se ns iti vi ty an al ys is Ou tc om ed Fi na nc ia l Ec on om ic Di st rib ut io nb Co nt in uo us Fu ll su bs id y (f re e) ; r ou ti ne he al th s er vi ce s (A N C cl in ic ) an d/ or c om m un it y- ba se d AN C cl in ic s t o PW (f re e) ; im pl em en te d in 2 00 6 Bu rk in a Fa so , 1 di st ric t ( Ko ss i)2 2 So ci et al , 20 06 –2 00 7 AN C cl in ic : p ro vi de r co st s f or M oH , in cl ud in g tra in in g, su pe rv isi on , L LI N tra ns po rt Ca pi ta l c os ts a nn ua liz ed (L LI N s o ve r 5 y , v eh ic le s o ve r 7 y) a nd d isc ou nt ed (3 % ); al l pr ic es a t 2 00 6 le ve ls w er e co nv er te d to U S do lla rs ; de ta ile d op po rt un ity c os ts w er e ca lc ul at ed fo r s pa ce a nd pe rs on ne l o n pr oj ec t AN C cl in ic : I TN s, 23 % ; tra ns po rt , 1 5% ; s ta ff, 54 % LL IN , 5 y ea rs (p hy sic al a nd tre at m en t) D isc ou nt ra te ; L LI N lif es pa n; c os ts of tr an sp or t, pe rs on ne l, re nt a nd IE C m at er ia ls; le ak ag e of LL IN s Fi na nc ia l c os t p er L LI N d el iv er ed , U S$ 8 .2 0; ec on om ic c os t p er L LI N d el iv er ed , U S$ 5 .4 7 (ra ng e: 5 .3 8– 6. 83 ); al l o ut co m es w er e m os t s en sit iv e to L LI N li fe sp an a nd le ak ag e Fr om 2 00 1, A N C cl in ic s t o PW (fr ee ) a nd in H F an d CH W to G P (fu ll co st ; f re e af te r 2 00 3) Er itr ea , n at io na l (S te ve ns )25 Pr ov id er , 20 01 –2 00 5 Al l d ire ct c os ts to pr ov id er , i nc lu di ng co m m od iti es , de liv er y, IE C ac tiv iti es , s ta ff, ta xe s Ca pi ta l c os ts w er e an nu al ize d an d di sc ou nt ed (3 % ); al l p ric es at 2 00 5 le ve ls co nv er te d to U S do lla rs ; S ha re d co st s fo r p er so nn el a nd sp ac e on pr oj ec t c al cu la te d IT N s a nd in se ct ic id e, 64 % ; s ta ff, 2 1% IT N , 3 -y ea r ph ys ic al lif es pa n; ne w IT N o r re tre at m en t pr ov id e 1 TN Y D isc ou nt ra te ; IT N c os t, us e, lif es pa n an d eff ec tiv en es s; pr op or tio n of sh ar ed c os ts O ut co m es m os t s en sit iv e to IT N c os ts a nd sh ar ed c os t a llo ca tio n: fi na nc ia l c os t p er IT N d el iv er ed , U S$ 1 0. 67 ; fi na nc ia l c os t pe r T N Y, U S$ 3 .2 3; e co no m ic c os t p er IT N de liv er ed , U S$ 9 .0 0 (ra ng e: 7 .4 4– 23 .2 9) ; ec on om ic c os t p er T N Y, U S$ 2 .7 4 O ut co m es m os t s en sit iv e to IT N eff ec tiv en es s a nd u se : c os t p er c hi ld d ea th av er te d, U S$ 3 27 6 (ra ng e: 1 63 7– 13 1 04 ); co st p er D AL Y av er te d, U S$ 1 00 (r an ge : 81 –3 98 ) AN C cl in ic s t o PW (f re e) in 2 00 1 Ke ny a, 3 5 di st ric ts 26 Pr ov id er , 2 00 1 IT N s a nd tr an sp or t (in te rn at io na l, t o di st ric t, to A N C fa ci lit ie s) N ot re po rt ed N ot re po rt ed N ot re po rt ed N ot re po rt ed Fi na nc ia l c os t p er IT N d el iv er ed to A N C cl in ic s, U S$ 7 .6 4; fi na nc ia l c os t p er IT N de liv er ed to P W , U S$ 1 0. 54 AN C cl in ic s t o PW (f re e) in 2 00 7 U ga nd a, 2 di st ric ts (A dj um an i, Jin ja )27 Pr ov id er , 2 00 7 D et ai le d co st s o f LL IN s, tra ns po rt , st or ag e, di st rib ut io n, IE C ac tiv iti es , t ra in in g, pe rs on ne l Ca pi ta l c os ts a nn ua liz ed (I TN s ov er 3 y , v eh ic le s o ve r 7 .5 y ); sh ar ed c os ts o f p er so nn el tim e an d ov er he ad ; a ll co st s w er e in cu rre d in 2 00 7, so no in fla tio n ad ju st m en t w as m ad e; p ric es c on ve rt ed to U S do lla rs LL IN tr an sp or t, 33 % ; IE C, 2 3% ; t ra in in g, 2 3% ; an d m an ag em en t, 12 % e LL IN , 3 y ea rs (p hy sic al a nd tre at ed ) D isc ou nt ra te ; LL IN li fe sp an an d co st ; ne t u se a nd re te nt io n Fi na nc ia l c os t p er L LI N d el iv er ed , U S$ 8 .8 3; ec on om ic c os t p er L LI N d el iv er ed , U S$ 5 .8 9 (ra ng e: 4 .9 3– 7. 08 ); ec on om ic co st p er T N Y, U S$ 1 .9 6; a ll ou tc om es w er e m os t s en sit iv e to L LI N li fe sp an (c on tin ue s. . . ) 678 Bull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771 Systematic reviews Insecticide-treated nets for malaria control Barbara A Willey et al. De liv er y s tr at eg y Co un tr y, sc al e Pe rs pe ct iv e, in te rv al Co st Ne t l ife sp an c Se ns iti vi ty an al ys is Ou tc om ed Fi na nc ia l Ec on om ic Di st rib ut io nb Pa rt ia l s ub si dy ; r ou ti ne he al th s er vi ce s (H Fs ; A N C an d/ or M CH c lin ic s) a nd /o r re ta ile rs a nd /o r c om m un it y- ba se d Re ta il to G P (p ar tia l s ub sid y) ; im pl em en te d in 2 00 6 Bu rk in a Fa so , 1 di st ric t ( Ko ss i)2 2 So ci et al , 20 06 –2 00 7 Re ta ile r: pr ov id er co st s i nc ur re d by N GO , w ho le sa le rs an d sh op ke ep er s, in cl ud in g tra ns po rt , st or ag e, la bo ur , pr ofi t, IE C m at er ia ls Ca pi ta l c os ts a nn ua liz ed (L LI N s o ve r 5 y , v eh ic le s o ve r 7 y) a nd d isc ou nt ed (3 % ); al l pr ic es a t 2 00 5 le ve ls w er e co nv er te d to U S do lla rs ; de ta ile d op po rt un ity c os ts fo r s pa ce a nd p er so nn el ; us er c on tri bu tio n ca lc ul at ed di ffe re nc e be tw ee n pr ov id er ’s fin an ci al c os ts a nd a ct ua l c os ts re co ve re d Re ta il: IT N s, 23 % ; w ho le sa le r/ re ta ile rs , 25 % ; s ta ff 22 % LL IN , 5 y ea rs (p hy sic al a nd tre at m en t) D isc ou nt ra te ; L LI N lif es pa n; c os ts of tr an sp or t, pe rs on ne l, re nt a nd IE C m at er ia ls; le ak ag e of LL IN s Fi na nc ia l c os t p er L LI N d el iv er ed , U S$ 9 .1 9; ec on om ic c os t p er L LI N d el iv er ed , U S$ 5 .4 7 (ra ng e: 5 .3 8– 6. 83 ); al l o ut co m es w er e m os t s en sit iv e to L LI N li fe sp an a nd le ak ag e Fr om 2 00 2, M CH c lin ic s t o PW an d ch ild re n < 5 ; a fte r 2 00 3, to GP b y co m m un ity -b as ed g ro up s (p ar tia l s ub sid y) M al aw i, na tio na l3 Pr ov id er , 19 99 –2 00 3 Ca pi ta l a nd re cu rre nt c os ts , in cl ud in g IT N s, ve hi cl es , s ta ff, br an d cr ea tio n, ad ve rt isi ng , pr om ot io n Ca pi ta l c os ts a nn ua liz ed (IT N s o ve r 5 y , b ra nd o ve r 7 y, ve hi cl es o ve r 8 y ) a nd di sc ou nt ed (3 % ); al l p ric es a t 19 99 le ve ls co nv er te d to U S do lla rs IT N s, 55 % ; s ta ff, 1 0% ; su pp lie s/ o ve rh ea d, 10 % ; f ue l, 9 % IT N , 5 -y ea r ph ys ic al lif es pa n; tre at m en t pr ov id es 0 .5 TN Y N ot re po rt ed Av er ag e ec on om ic c os t p er IT N d el iv er ed , U S$ 1 1. 16 (d ec re as ed fr om U S$ 2 1. 39 in 19 99 to U S$ 8 .1 5 in 2 00 3 as n um be r o f IT N s d ist rib ut ed in cr ea se d, su gg es tin g ec on om ie s o f s ca le ); av er ag e ec on om ic co st p er T N Y, U S$ 1 8. 72 (d ec re as ed fr om U S$ 3 2. 64 in 1 99 9 to U S$ 1 4. 60 in 2 00 3) Fr om 1 99 7; H F, co m m un ity - ba se d de liv er y an d re ta ile rs to GP (p ar tia l s ub sid y) U ni te d Re pu bl ic of Ta nz an ia , 2 di st ric ts (K ilo m be ro , U la ng a) 36 Pr ov id er , u se r, 19 96 –2 00 0 Ca pi ta l a nd re cu rre nt c os ts di vi de d in to se t- up (b ra nd in g, se ns iti za tio n) a nd on go in g su pp ly (IT N s, pe rs on ne l, tra ns po rt , t ra in in g, pr om ot io n) Ca pi ta l c os ts a nn ua liz ed (IT N s o ve r 5 y , b ra nd o ve r 7 y, ve hi cl es o ve r 1 0 y) a nd di sc ou nt ed (3 % ); op po rt un ity co st s p ro vi de rs a nd u se rs (in cl ud in g pr ic e fo r I TN ); al l pr ic es a t 2 00 0 le ve ls co nv er te d to U S do lla rs IT N s a nd in se ct ic id e, 31 % ; s ta ff, 2 8% ; o th er re cu rre nt c os ts , 3 2% IT N , 5 -y ea r ph ys ic al lif es pa n; tre at m en t pr ov id es 0 .5 TN Y H ea lth m ea su re s ( IT N co ve ra ge , in cl us io n of un tre at ed ne ts , du ra tio n of eff ec tiv en es s) Ec on om ic c os t p er T N Y, U S$ 2 5. 09 a nd U S$ 1 2. 57 if in se ct ic id e la st s 6 a nd 1 2 m on th s, re sp ec tiv el y; e co no m ic c os t p er ch ild d ea th a ve rt ed , U S$ 2 92 4 (ra ng e: 11 01 –1 90 9) ; e co no m ic c os t p er D AL Y av er te d, U S$ 1 07 (r an ge : 4 1– 69 ); al l ou tc om es w er e se ns iti ve to a ll m ea su re d as su m pt io ns Fr om 2 00 4, A N C cl in ic s t o PW (p ar tia l s ub sid y vi a vo uc he r a t re ta ile r) U ni te d Re pu bl ic of Ta nz an ia , na tio na l35 Pr ov id er , u se r, 20 04 –2 00 6 Ca pi ta l a nd re cu rre nt c os ts , in cl ud in g fo rm at iv e re se ar ch , p la nn in g, tra in in g, v eh ic le s, IT N s, IE C, p er so nn el , ov er he ad Ca pi ta l c os ts a nn ua liz ed (I TN s ov er 3 y , v eh ic le s o ve r 8 y ) a nd di sc ou nt ed (3 % ); op po rt un ity co st s f or p ro vi de rs a nd u se rs (in cl ud in g to p up p ai d fo r IT N ); al l p ric es a t 2 00 6 le ve ls co nv er te d to U S le ve ls IT N : 2 0% su bs id ise d, 8% to u se r 8 % ; s ta ff, 25 % ; p ro m ot io n ac tiv iti es , 1 6% IT N , 3 -y ea r ph ys ic al lif es pa n; ne w IT N o r re tre at m en t pr ov id e 1 TN Y D isc ou nt ra te ; us er to p up ; IT N p ric e, eff ec tiv e lif es pa n an d re -t re at m en t us e; L LI N s Fi na nc ia l c os t p er IT N d el iv er ed , U S$ 1 2. 09 ; e co no m ic c os t p er IT N de liv er ed , U S$ 1 0. 77 (r an ge : 1 0. 53 –1 2. 23 ); ec on om ic c os t p er T N Y, U S$ 6 .0 2 (ra ng e: 5 .8 8– 12 .0 3] ; e co no m ic c os t p er ch ild d ea th a ve rt ed , U S$ 1 2 42 (r an ge : 1 21 9– 24 96 ); al l o ut co m es w er e m os t se ns iti ve to IT N li fe sp an a nd u se (. . . co nt in ue d) (c on tin ue s. . . ) 679Bull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771 Systematic reviews Insecticide-treated nets for malaria controlBarbara A Willey et al. De liv er y s tr at eg y Co un tr y, sc al e Pe rs pe ct iv e, in te rv al Co st Ne t l ife sp an c Se ns iti vi ty an al ys is Ou tc om ed Fi na nc ia l Ec on om ic Di st rib ut io nb Ti m e- lim ite d Fu ll su bs id y (f re e) ; s ta nd - al on e ca m pa ig n St an d- al on e ne t c am pa ig n to ch ild re n < 5 (f re e) in 2 00 7 U ga nd a, 2 di st ric ts (A dj um an i, Jin ja )27 Pr ov id er , 2 00 7 D et ai le d co st s o f LL IN s, tra ns po rt , st or ag e, di st rib ut io n, IE C ac tiv iti es , t ra in in g, pe rs on ne l Ca pi ta l c os ts a nn ua liz ed (I TN s ov er 3 y , v eh ic le s o ve r 7 .5 y ); Sh ar ed c os ts o f p er so nn el tim e an d ov er he ad s; al l c os ts w er e in cu rre d in 2 00 7, so no in fla tio n ad ju st m en t w as m ad e; p ric es c on ve rt ed to U S do lla rs D ist rib ut io n, 3 0% ; LL IN tr an sp or t, 15 % ; re gi st ra tio n, 1 6% ; I EC , 13 % e LL IN , 3 y ea rs (p hy sic al a nd tre at ed ) D isc ou nt ra te , LL IN li fe sp an an d co st ; ne t u se a nd re te nt io n Fi na nc ia l c os t p er L LI N d el iv er ed , U S$ 8 .3 0 (J in ja ) a nd U S$ 9 .4 9 (A dj um an i); ec on om ic c os t p er L LI N d el iv er ed , U S$ 3 .8 6 (J in ja ) a nd U S$ 4 .7 6 (A dj um an i) (ra ng e: 2 .9 1– 6. 06 ); ec on om ic c os t p er T N Y, U S$ 1 .2 9 (J in ja ) a nd U S$ 1 .5 8 (A dj um an i); al l o ut co m es w er e m os t s en sit iv e to L LI N lif es pa n Fu ll su bs id y (f re e) ; i nt eg ra te d w it h pu bl ic h ea lt h ca m pa ig n D ist rib ut io n in te gr at ed w ith m ea sle s v ac ci na tio n ca m pa ig n to c hi ld re n < 5 (f re e) in 2 00 2 Gh an a, 1 d ist ric t (L aw ra )30 Pr ov id er , 2 00 2 IT N s, tra ns po rt at io n, tra in in g, su pe rv isi on , s oc ia l m ob ili za tio n; ca m pa ig n co st s th at w ou ld h av e be en in cu rre d fo r m ea sle s va cc in at io n w ith ou t in cl us io n of IT N s w er e ex cl ud ed N ot re po rt ed Fi na nc ia l c os ts o nl y; IT N s, 91 % ; o th er el em en ts o f d el iv er y, 9% N ot re po rt ed N ot re po rt ed Fi na nc ia l c os t p er IT N d el iv er ed , U S$ 1 1. 53 D ist rib ut io n in te gr at ed w ith m ea sle s v ac ci na tio n ca m pa ig n to c hi ld re n < 5 (f re e) in 2 00 5 U ni te d Re pu bl ic of Ta nz an ia , 1 re gi on (L in di )45 Pr ov id er , 2 00 5 IT N s, tra ns po rt to d ist ric t, IE C ac tiv iti es , N M CP st aff N ot in cl ud ed Fi na nc ia l c os ts o nl y: IT N s 8 8% ; o th er el em en ts o f d el iv er y, 12 % N ot re po rt ed N ot re po rt ed Fi na nc ia l c os t p er IT N d el iv er ed , U S$ 3 .7 1 D ist rib ut io n in te gr at ed w ith m ea sle s v ac ci na tio n ca m pa ig n to c hi ld re n < 5 Za m bi a, 5 di st ric ts (C hi lu bi , K ap ut a, M am bw e, N yi m ba , Ka la lu sh i49 Pr ov id er , 2 00 3 IT N s, tra ns po rt , tra in in g, IE C ac tiv iti es ; c am pa ig n co st s t ha t w ou ld ha ve b ee n in cu rre d fo r m ea sle s va cc in at io n w ith ou t in cl us io n of IT N s w er e ex cl ud ed N ot re po rt ed Fi na nc ia l c os ts o nl y: IT N s, 94 % ; o th er el em en ts o f d el iv er y, 6% N ot re po rt ed N ot re po rt ed Fi na nc ia l c os t p er IT N d el iv er ed , U S$ 1 0. 88 in ru ra l a re as a nd U S$ 1 1. 79 in u rb an a re as AN C, a nt en at al c ar e; C HW , c om m un ity h ea lth w or ke r; DA LY , d isa bi lit y- ad ju st ed li fe y ea r; GP , g en er al p op ul at io n; H F, he al th fa ci lit y; IE C, in fo rm at io n ed uc at io n co m m un ic at io n; L LI N , lo ng -la st in g in se ct ic id e- tre at ed n et ; M CH , m at er na l a nd c hi ld h ea lth ; M oH , m in ist ry o f h ea lth ; N GO , n on go ve rn m en ta l o rg an iza tio n; N M CP , n at io na l m al ar ia c on tro l p ro gr am m e; P W , p re gn an t w om en ; T N Y, tre at ed -n et -y ea r ( in co rp or at es IT N s a nd re tre at m en t k its d ist rib ut ed ); US $, U ni te d St at es d ol la rs . a S tu di es m ay a pp ea r i n m or e th an o ne c at eg or y if m ul tip le st ra te gi es w er e us ed to d el iv er IT N s a t s ca le o r i f s tra te gi es c ha ng ed o ve r t im e. b R ep or te d as th e pe rc en ta ge o f t ot al e co no m ic c os ts (u nl es s s pe ci fie d ot he rw ise ). O nl y m ai n co st s a re re po rte d. c D efi ne d as p hy sic al v ia bi lit y an d du ra tio n of in se ct ic id e pr ot ec tio n. d A dj us te d fo r i nfl at io n an d re po rte d in 2 01 0 US d ol la rs to a llo w c om pa ris on a cr os s d iff er en t c ou nt rie s a nd y ea rs . e R ep or te d as th e pe rc en ta ge o f t ot al c os ts , e xc lu di ng L LI N c os t. (. . . co nt in ue d) 680 Bull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771 Systematic reviews Insecticide-treated nets for malaria control Barbara A Willey et al. themselves, most often followed by staff and transport. Factors influencing ITN delivery Information on factors influencing delivery of ITNs at scale was available for 12 of 20 studies (Table 4). Important perceived influences on the delivery of ITNs at scale, from the perspective of actors involved, were categorized into those at the user level, the implementer or health system level and the policy level.52 Facilitators at the implementation level included provision of training and appropriate supervision and support. At the policy level, facilitators included involvement of relevant stakeholders during planning and implementation and cooperation across ministries, de- partments and sectors (e.g. health and retail). Several barriers were identified, including costs to users for partially subsidized strategies, variation in imple- mentation due to insufficient supplies of ITNs and vouchers and to poor commu- nication and adherence to distribution procedures, and, at the policy level, financial resources to sustain current and future distribution strategies. Discussion Strategies frequently used to deliver ITNs at scale reported in the published and grey literature include continuous delivery of partially subsidized ITNs through the health sector and retail outlets, continuous delivery of free ITNs though antenatal care clinics and time-limited delivery of free ITNs, either alongside other public health goods (usually vaccines) during integrated campaigns or through stand-alone ITN campaigns. Few experiences with con- tinuous delivery by community-based agents were recorded. The majority of strategies delivered to a targeted popu- lation of children under 5 or pregnant women. Seven studies from six countries described multiple concurrent or se- quential delivery strategies, particularly continuous strategies in combination with a time-limited campaign. These studies showed wide variabil- ity in ITN ownership among households and ITN use among children under 5. Although findings of high ownership or use were largely drawn from uncon- trolled studies, strategies reviewed in the majority of studies included at least one component that delivered ITNs at a full Ta bl e 4. Ba rr ie rs to a nd fa cil ita to rs o f s ca lin g up d el iv er y o f i ns ec tic id e- tr ea te d ne ts (I TN s) in a re as w ith e nd em ici ty fo r P la sm od iu m fa lci pa ru m a nd P la sm od iu m vi va x m al ar ia , b y d el iv er y s tr at eg y a nd im pl em en ta tio n le ve l Va ria bl e Co nt in uo us Ti m e- lim ite d At co st , p ar tia l s ub sid y o r n o su b- sid y; co m m un ity -b as ed 21 ,2 4 Fu ll su bs id y; AN Ca ,2 5– 27 Pa rt ia l s ub sid y; A NC a nd M CH cl in ics a, 3, 31 ,3 3, 39 ,4 0 Pa rt ia l s ub sid y; re - ta il3 ,2 3, 28 ,3 1, 33 ,3 9, 40 Fr ee ; s ta nd -a lo ne ca m - pa ig n2 7, 41 Fr ee ; c am pa ig n in te gr at - ed w ith p ub lic h ea lth ca m pa ig na ,4 8, 49 U se r l ev el Co st Ba rri er b – Ba rri er Ba rri er – – Im pl em en te r/ he al th s ys te m le ve l Fu nc tio ni ng o ut re ac h sy st em Fa ci lit at or – – – – – La ck o f c la rit y of g ui de lin es – Ba rri er – – Ba rri er – Tr ai ni ng a nd su pe rv isi on – Fa ci lit at or Fa ci lit at or Fa ci lit at or Fa ci lit at or Fa ci lit at or Im pl em en ta tio n by p ro vi de r n ot a cc or di ng to gu id el in es – Ba rri er Ba rri er Ba rri er – Ba rri er H ea lth st aff o ve rb ur de ne d – – – – – Ba rri er Re co rd k ee pi ng – Fa ci lit at or Fa ci lit at or – – – St oc k- ou t o f n et s o r v ou ch er s – – Ba rri er Ba rri er Ba rri er Ba rri er Po or lo gi st ic s f or p ro cu re m en t o r t ra ns po rt o f n et s – – Ba rri er – Ba rri er Ba rri er Po lic y le ve l St ak eh ol de r i nv ol ve m en t – Fa ci lit at or Fa ci lit at or Fa ci lit at or Fa ci lit at or Fa ci lit at or Co op er at io n be tw ee n de pa rt m en ts a nd m in ist rie s – Fa ci lit at or Fa ci lit at or Fa ci lit at or Fa ci lit at or Fa ci lit at or In st ab ili ty o f fi na nc in g Ba rri er Ba rri er – Ba rri er – – Re gu la tio n am en dm en t – – – Fa ci lit at or – – AN C, a nt en at al c ar e; M CH , m at er na l a nd c hi ld h ea lth . a I nf or m at io n w as p rin ci pa lly fr om d isc us sio n se ct io ns o f p ap er s, w ith th e fo llo w in g ex ce pt io ns : s ta ke ho ld er in te rv ie w s i n Gh an a, 31 K en ya 26 a nd N ig er ia 51 a nd c as e st ud y of sc al in g up IT N s i n th e Un ite d Re pu bl ic o f T an za ni a. 33 b F or p ar tia lly su bs id ise d de liv er y by c om m un ity v ol un te er s i n Za m bi a. 21 Bull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771 681 Systematic reviews Insecticide-treated nets for malaria controlBarbara A Willey et al. subsidy. The majority of equity evidence was from uncontrolled studies: in gen- eral, strategies that used time-limited delivery of fully subsidized ITNs were equitable or pro-poor, in contrast to strategies that used continuous delivery of partially subsidized ITNs. No equity evidence from fully subsidized continu- ous strategies was available. Comparisons of costs and cost- effectiveness across these strategies are challenging because of variations in the methods of economic analysis used and in the scale of delivery, as emphasized previously.53 Nonetheless, the cost of delivering ITNs across the strategies was reasonably comparable. The main cost was the ITNs themselves, a cost frequently supported by donor funding, and all of the cost-effectiveness estimates were most sensitive to ITN lifespan and proportion of ITNs actually used. This review aimed to synthesize de- tails on the context of, barriers to and fa- cilitators of strategies to deliver ITNs at scale, some of which were implemented under near-programmatic conditions. Important factors influencing the deliv- ery of ITNs at scale were similar across delivery strategies. Barriers involving cost were common at the user level, whereas barriers involving stock-outs and poor logistics for ITN procure- ment and transport were common at the implementer level. Training and su- pervision of staff was often highlighted as a facilitator at the implementer level and cooperation across departments or ministries and stakeholder involvement were highlighted at the policy level. The evaluation of large-scale health programmes has been highlighted as a “top priority in global health”54 and researchers have emphasized that the use of randomized designs for such evaluation may be inappropriate because of low external validity.11,55 Therefore, to characterize the full breadth of ITN delivery strategies and to synthesize evidence that corresponded to the conditions under which large-scale ITN delivery may occur in practice, we included a variety of study designs.56 However, this made interpretation of findings challenging, particularly be- cause a before-and-after study of a cam- paign conducted at a single time point is qualitatively different from annual surveys conducted during a continuous distribution strategy. The Medical Research Council recommends that the evaluation of complex interventions include informa- tion on the context and implementation of interventions. Our experience in conducting this review suggests that future synthesis of evidence involving large-scale delivery of complex public health interventions would benefit from improved consistency of report- ing of the implementation process by included studies.57,58 Recommendations for reporting are available from the Transparent Reporting of Evaluations with Nonrandomized Designs (TREND) statement.59 It is simplistic to interpret the findings of this review as providing a single recommendation to policy- makers on which ITN delivery strategy to adopt. Rather, the review highlights that choosing among alternatives de- pends on contextual factors, such as the epidemiologic characteristics of malaria, attributes of health systems and contextual constraints. Moreover, the review demonstrates how a framework for characterizing delivery strategies can prove useful in synthesizing evi- dence, which may help policy-makers formulate implementation strategies to deliver ITNs to populations in their local settings. ■ Acknowledgements We thank Mark Petticrew and Neil Spic- er (Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine) and Rifat Atun (Imperial Col- lege London, formerly with The Global Fund to Fight AIDS, Tuberculosis and Malaria) for helpful comments. Funding: This review was supported by the Alliance for Health Services and Policy Research, World Health Organization, which commissioned this work as a background paper for the First Global Symposium on Health Systems Research. Competing interests: None declared. صخلم ضارعتسا :ايرلالما ةحفاكلم عساو قاطن لىع تاشرلحا تاديبمب ةلجاعلما تايسومانلا ءاتيإ لىإ ةيمارلا تايجيتاترسلاا يجهنم تايجيتاترسلال ةثيدلحا تاساردلا نم جئاتنلا صلاختسا ضرغلا قاطن لىع تاشرلحا تاديبمب ةلجاعلما تايسومانلا ءاتيإ لىإ ةيمارلا .ايرلالما اهنطوتت يتلا قطانلما في عساو ينب ةروشنلما تاساردلا نع تانايبلا دعاوق في ثحبلا مت ةقيرطلا يتلا 2010 برمسيد/لولأا نوناكو 2000 رياني/نياثلا نوناك ةروصتلما ايرلام اهنطوتت قطانم في ينميقلما صاخشلأا :تنمضت ةلجاعلما تايسومانلا ءاتيإ مييقت متو ؛ةطيشنلا ةروصتلماو ةيلجنلما تايسومانلا كلاتما لدعمو ؛عساو قاطن لىع تاشرلحا تاديبمب تاديسلا ملست مييقت متو ،سرلأا ينب تاشرلحا تاديبمب ةلجاعلما نع مهرماعأ لقت نيذلا لافطلأا ينب اهمادختسا وأ/و اله لماولحا يدرف وحن لىع ةبقارملل ًاعضاخ ةساردلا ميمصت ناكو ؛تاونس 5 يدعبو ليبق وأ يبيرتج هبش وأ يئاوشع يرغ وأ يدوقنع يئاوشع وأ ةينمز طباوض نود تاعاطقلا ةددعتم وأ ةعطقتم ةينمز لسلاس وأ تاساردلا فصت يتلا قارولأا جاردإ كلذك متو .ةيفارغج وأ ةيدودرلما تاساردو ةيلمعلا تماييقتو ةلالحا تاساردو ةيعونلا مادختساب ةساردلا ةيعون مييقت متو .ةلهؤم ةقروب ةطبترلما يرياعمو زيحتلل ةيعجرلما ةمئاقلاب ةينعلما نيركوك رطامخ ةيجهنم برع اهمييقتو زيزعتلا لىع ةمالها تايرثأتلا ديدتح متو .GRADE .ءاتيلإا تايجيتاترسا ةسارد 20 فصت ةقرو 32 هيلاجمإ ام ضارعتسا مت جئاتنلا تاعاطق ءاتيلإا تايجيتاترسا نم ديدعلا تنمضتو .ةيقيرفأ ةياعرلا تادايعو )ةيئزلجا ةناعلإا( ةئزجتلاب عيبلا ذفانمو ةحصلا .)ةيلكلا ةناعلإا( تلاملحاو )ةيلكلا ةناعلإا( ةدلاولل ةقباسلا سرلأا ينب عفترم كلاتما لدعم ققتح يتلا تايجيتاترسلاا تدأو لىإ تاونس 5 نع مهرماعأ لقت نيذلا لافطلأا ينب مادختسلااو قيرط نع ناجلماب تاشرلحا تاديبمب ةلجاعلما تايسومانلا ءاتيإ برع عساو قاطن لىع ةنراقملل ةلباق فيلاكتلا تناكو .تلاملحا تاشرلحا تاديبمب ةلجاعلما تايسومانلا تناكو ؛تايجيتاترسلاا ةيساسح رثكأ ةيدودرلما تاريدقت تناكو .ةيسيئرلا ةفلكتلا يه زجاولحا تنمضتو .تايسومانلل ينضترفلما بسرتلاو رمعلل Bull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771682 Systematic reviews Insecticide-treated nets for malaria control Barbara A Willey et al. .تايتسيجوللا فعضو نوزخلما دافنو ةفلكتلا ءاتيلإا مامأ ةعئاشلا مهيلع فاشرلإاو ينلماعلا بيردت في ةعئاشلا يرسيتلا هجوأ تلثتمو .ةحلصلما باحصأ كاشرإو تارازولا وأ تارادلإا برع نواعتلاو ءاتيإب ةينعلما تايجيتاترسلال عساو فينصت ةمث جاتنتسلاا .عساو قاطن لىع تاشرلحا تاديبمب ةلجاعلما تايسومانلا 摘要 大规模发放驱虫蚊帐预防疟疾的策略:系统性综述 目的 综合在疟疾流行地区大规模发放驱虫蚊帐(ITN)战略 的新近研究结果。 方法 在数据库中对在2000 年1 月至2010 年12 月发表的 研究报告进行检索,入选条件:研究对象居住在恶性疟原虫和 间日疟原虫疟疾流行地区;评估了大规模发放ITN;评估了家 庭中ITN的所有权、由孕妇接收和/或在年龄<5 岁的儿童 中使用的情况;研究设计采用单病例或群组随机对照,非随 机、准实验、前后设计、间歇时间序列设计或无时间或地 区对照的横断设计。描述入选论文相关的定性研究、个案 研究、措施评价和成本效益研究的论文也纳入分析。使用 Cochrane偏倚风险表和GRADE标准评估研究的质量。识别 并评估在发放策略中对扩大干预的重要影响。 结果 总共纳入了涉及20 项非洲研究的32 篇论文。许多 发放策略涉及卫生部门和零售网点(部分补贴)、产前保健 诊所(全额补贴)和活动(全额补贴)。通过宣传免费发放ITN 的策略实现了在家庭中的高所有权和在年龄<5 岁的儿童中 的高利用率。各种策略的成本大体相同;ITN 是主要成本。 成本效益估计对假设的净使用寿命和破损最为敏感。发放 的常见障碍包括成本、缺货和不完善的物流。共同的促进 因素是工作人员培训和监督、跨部门或部委合作和利益相 关者的参与。 结论 大规模发放ITN具有多种策略。 Résumé Stratégies de distribution de moustiquaires imprégnées adaptées à la lutte contre le paludisme: revue systématique Objectif Réaliser une synthèse des études récentes menées sur les stratégies permettant de fournir des moustiquaires imprégnées d’insecticide (MMI) à grande échelle dans les zones où le paludisme est endémique. Méthodes À partir de bases de données, on a recherché les études publiées entre janvier 2000 et décembre 2010, dans lesquelles: les sujets résidaient dans des zones où le paludisme à Plasmodium falciparum et à Plasmodium vivax était endémique; une distribution à grande échelle de MMI a été évaluée; la détention de MMI dans les foyers, la réception par les femmes enceintes et/ou l’utilisation chez les enfants âgés de moins de 5 ans a été évaluée; la conception de l’étude impliquait un contrôle individuel ou en grappes, était quasi expérimentale, avant et après, en séries temporelles interrompues, ou transversale sans contrôle temporel ou géographique. Les documents de travail décrivant les études qualitatives, les études de cas et les études d’évaluation des processus et de rentabilité, associés à un document de travail éligible, ont également été inclus. La qualité des études a été appréciée à l’aide de la liste de vérification des risques Cochrane et des critères de l’approche GRADE. On a relevé et évalué d’importantes influences sur l’augmentation de la distribution dans les différentes stratégies. Résultats Un total de 32 documents de travail décrivant 20 études africaines a été étudié. Bon nombre des stratégies de distribution impliquaient différents secteurs de la santé, ainsi que le réseau du commerce de détail (partiellement subventionné), les maternités (intégralement subventionnées) et les campagnes (intégralement subventionnées). Les stratégies qui ont obtenu une meilleure détention dans les foyers et une plus grande utilisation chez les enfants âgés de moins de 5 ans étaient les campagnes de distribution gratuite des MMI. Les coûts étaient largement comparables dans les stratégies étudiées, les MMI constituant le principal coût. Les estimations de rentabilité variaient surtout en fonction de la durée de vie et de la résistance présumée de la moustiquaire. Parmi les inconvénients les plus courants figuraient le coût, la rupture de stock et une mauvaise logistique. Les facteurs favorables les plus courants étaient la formation et la supervision du personnel, la coopération interdépartementale ou interministérielle, ainsi que l’implication des intervenants. Conclusion Il existe une vaste taxonomie de stratégies pour une distribution à grande échelle des MMI. Резюме Стратегии масштабной поставки сеток, обработанных инсектицидом, в борьбе с малярией: систематический обзор Цель Обобщить результаты последних исследований стратегий масштабной поставки сеток, обработанных инсектицидом (ITN), в районах, для которых малярия является эндемическим заболеванием. Методы В базах данных производился поиск исследований, опубликованных с января 2000 г. по декабрь 2010 г., в которых: субъекты проживали в районах, для которых малярия, вызванная Plasmodium falciparum и Plasmodium vivax, является эндемическим заболеванием; оценивалась масштабная поставка ITN; оценивались использование ITN домашними хозяйствами и применение для защиты беременных женщин и/или детей в возрасте до 5 лет; при этом применялся план индивидуального или кластер-рандомизированного контролируемого исследования, нерандомизированного, квази-экспериментального, «до и после», прерванного временного ряда или перекрестного без временного или географического контроля. Также включались статьи, описывающие качественные исследования, ситуационные исследования, оценки процессов и исследования эффективности затрат, связанные с рассматриваемой работой. Качество исследований оценивалось с помощью Кокрановского контрольного списка для оценки риска систематической ошибки и критериев GRADE. Для стратегий поставки были выявлены и оценены факторы, оказывающие существенное влияние на увеличение масштаба. Результаты Всего рассмотрено 32 работы с описанием 20 исследований, проведенных в Африке. Во многих стратегиях поставки участвовали секторы здравоохранения и точки розничной торговли (частичное субсидирование), клиники Bull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771 683 Systematic reviews Insecticide-treated nets for malaria controlBarbara A Willey et al. дородовой помощи (полное субсидирование), а также практиковалось проведение кампаний (полное субсидирование). Наибольшее использование ITN в домашних хозяйствах и для защиты детей в возрасте до 5 лет достигалось с применением в ходе кампаний стратегий бесплатного распространения. Затраты при различных стратегиях были в значительной степени соизмеримы; основную часть затрат составляла стоимость ITN. Оценки эффективности затрат были наиболее чувствительны к предполагаемому сроку службы сеток и степени пропускания насекомых. Среди наиболее распространенных факторов, препятствующих поставке, были стоимость, дефицит и плохая логистика. Среди способствующих поставке факторов были обучение персонала и надзор за его деятельностью, сотрудничество между министерствами и ведомствами, а также вовлечение заинтересованных сторон. Вывод Имеется широкая систематика стратегий масштабных поставок ITN. Resumen Estrategias para la distribución a escala de mosquiteros tratados con insecticida para controlar la malaria: revisión sistemática Objetivo Sintetizar los resultados de estudios recientes acerca de las estrategias para distribuir a escala mosquiteros tratados con insecticida (RTI) en zonas con malaria endémica. Métodos Se examinaron bases de datos en busca de estudios publicados entre enero de 2000 y diciembre de 2010 en los que: los sujetos residían en áreas en las que la malaria por Plasmodium falciparum y Plasmodium vivax es endémica; se evaluó la entrega de RTI a escala; se evaluó la propiedad de RTI en hogares, la recepción por parte de mujeres embarazadas y/o el uso por parte de niños menores de 5 años; y cuyo diseño del estudio era un estudio controlado individual o aleatorio sobre grupos, no aleatorio, cuasiexperimental, antes y después, de series de tiempo interrumpido o transversal sin controles temporales o geográficos. También se incluyeron artículos que describían estudios cualitativos, estudios de caso, evaluaciones de proceso y estudios de efectividad de costes vinculados a un artículo que cumplía con las condiciones. La calidad del estudio fue evaluada por medio de la herramienta Cochrane de riesgo de sesgo y los criterios GRADE. Se identificaron y evaluaron importantes influencias sobre el aumento progresivo en las estrategias de distribución. Resultados Se revisaron un total de 32 artículos que describían 20 estudios africanos. En muchas de las estrategias de distribución participaron sectores sanitarios y establecimientos de venta al por menor (subsidio parcial), clínicas de atención prenatal (subsidio completo) y campañas (subsidio completo). Las estrategias que consiguieron un grado de participación entre los hogares y un uso entre niños menores de 5 años elevados distribuyeron RTI de forma gratuita mediante campañas. Los costes de las diversas estrategias fueron en gran medida comparables; las RTI supusieron el coste principal. Los cálculos de efectividad de costes fueron sensibles sobre todo a la vida útil esperada del mosquitero y a las fugas. Entre las barreras frecuentes a la distribución figuraron el coste, la falta de existencias y una logística deficiente. 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Household ownership and use of insecticide treated nets among target groups after implementation of a national voucher programme in the United Republic of Tanzania: plausibility study using three annual cross sectional household surveys. BMJ 2009;339:b2434. doi:10.1136/bmj.b2434 PMID:19574316 33. Magesa SM, Lengeler C, deSavigny D, Miller JE, Njau RJA, Kramer K et al. Creating an “enabling environment” for taking insecticide treated nets to national scale: the Tanzanian experience. Malar J 2005;4:34. doi:10.1186/1475-2875-4-34 PMID:16042780 34. Marchant T, Schellenberg D, Nathan R, Armstrong-Schellenberg J, Mponda H, Jones C et al. Assessment of a national voucher scheme to deliver insecticide-treated mosquito nets to pregnant women. CMAJ 2010;182:152–6. doi:10.1503/cmaj.090268 PMID:20064944 35. Mulligan JA, Yukich J, Hanson K. Costs and effects of the Tanzanian national voucher scheme for insecticide-treated nets. Malar J 2008;7:32. doi:10.1186/1475-2875-7-32 PMID:18279509 36. Hanson K, Kikumbih N, Armstrong Schellenberg J, Mponda H, Nathan R, Lake S et al. Cost-effectiveness of social marketing of insecticide-treated nets for malaria control in the United Republic of Tanzania. Bull World Health Organ 2003;81:269–76. PMID:12764493 37. Kikumbih N, Hanson K, Mills A, Mponda H, Schellenberg JA. The economics of social marketing: the case of mosquito nets in Tanzania. Soc Sci Med 2005;60:369–81. doi:10.1016/j.socscimed.2004.05.005 PMID:15522492 38. Schellenberg JR, Abdulla S, Nathan R, Mukasa O, Marchant TJ, Kikumbih N et al. Effect of large-scale social marketing of insecticide-treated nets on child survival in rural Tanzania. Lancet 2001;357:1241–7. doi:10.1016/S0140- 6736(00)04404-4 PMID:11418148 39. Chavasse D, Kolwicz C, Smith B. Preventing malaria in Malawi. Essent Drugs Monit 2001;3:2–3. 40. The Malawi ITN delivery model. Washington: Population Services International; 2005. 41. Beer N, Ali A, de Savigny D, Al-Mafazy AW, Ramsan M, Abass A et al. System effectiveness of a targeted free mass distribution of long lasting insecticidal nets in Zanzibar, Tanzania. Malar J 2010;9:173. doi:10.1186/1475-2875-9-173 PMID:20565860 42. Hightower A, Kiptui R, Manya A, Wolkon A, Vanden Eng J, Hamel M et al. Bed net ownership in Kenya: the impact of 3.4 million free bed nets. Malar J 2010;9:183. doi:10.1186/1475-2875-9-183 PMID:20576145 43. Noor AM, Amin AA, Akhwale WS, Snow RW. Increasing coverage and decreasing inequity in insecticide-treated bed net use among rural Kenyan children. PLoS Med 2007;4:e255. doi:10.1371/journal.pmed.0040255 PMID:17713981 44. Kulkarni MA, Vanden Eng J, Desrochers RE, Cotte AH, Goodson JL, Johnston A et al. Contribution of integrated campaign distribution of long-lasting insecticidal nets to coverage of target groups and total populations in malaria-endemic areas in Madagascar. Am J Trop Med Hyg 2010;82:420–5. doi:10.4269/ajtmh.2010.09-0597 PMID:20207867 45. Skarbinski J, Massaga JJ, Rowe AK, Kachur SP. Distribution of free untreated bednets bundled with insecticide via an integrated child health campaign in Lindi Region, Tanzania: lessons for future campaigns. Am J Trop Med Hyg 2007;76:1100–6. PMID:17556618 46. Khatib RA, Killeen GF, Abdulla S, Kahigwa E, McElroy PD, Gerrets RPM et al. Markets, voucher subsidies and free nets combine to achieve high bed net coverage in rural Tanzania. Malar J 2008;7:98. doi:10.1186/1475-2875-7-98 PMID:18518956 47. Centers for Disease Control and Prevention (CDC). Distribution of insecticide-treated bednets during an integrated nationwide immunization campaign – Togo, West Africa, December 2004. MMWR Morb Mortal Wkly Rep 2005;54:994–6. PMID:16208313 48. Terlouw DJ, Morgah K, Wolkon A, Dare A, Dorkenoo A, Eliades MJ et al. Impact of mass distribution of free long-lasting insecticidal nets on childhood malaria morbidity: the Togo National Integrated Child Health Campaign. Malar J 2010;9:199. doi:10.1186/1475-2875-9-199 49. Grabowsky M, Farrell N, Hawley W, Chimumbwa J, Hoyer S, Wolkon A et al. Integrating insecticide-treated bednets into a measles vaccination campaign achieves high, rapid and equitable coverage with direct and voucher-based methods. Trop Med Int Health 2005;10:1151–60. doi:10.1111/j.1365-3156.2005.01502.x PMID:16262740 50. Thwing J, Hochberg N, Vanden Eng J, Issifi S, Eliades MJ, Minkoulou E et al. Insecticide-treated net ownership and usage in Niger after a nationwide integrated campaign. Trop Med Int Health 2008;13:827–34. doi:10.1111/ j.1365-3156.2008.02070.x PMID:18384476 51. Blackburn BG, Eigege A, Gotau H, Gerlong G, Miri E, Hawley WA et al. Successful integration of insecticide-treated bed net distribution with mass drug administration in Central Nigeria. Am J Trop Med Hyg 2006;75:650–5. PMID:17038688 52. Hanson K, Ranson MK, Oliveira-Cruz V, Mills A. Expanding access to priority health interventions: a framework for understanding the constraints to scaling-up. J Int Dev 2003;15:1–14. doi:10.1002/jid.963 53. Kolaczinski J, Hanson K. Costing the distribution of insecticide-treated nets: a review of cost and cost-effectiveness studies to provide guidance on standardization of costing methodology. Malar J 2006;5:37. doi:10.1186/1475-2875-5-37 PMID:16681856 54. Evaluation: the top priority for global health. Lancet 2010;375:526. doi:10.1016/S0140-6736(10)60056-6 PMID:20079530 55. Victora CG, Black RE, Boerma JT, Bryce J. Measuring impact in the Millennium Development Goal era and beyond: a new approach to large-scale effectiveness evaluations. Lancet 2011;377:85–95. doi:10.1016/ S0140-6736(10)60810-0 PMID:20619886 56. Shepperd S, Lewin S, Straus S, Clarke M, Eccles MP, Fitzpatrick R et al. Can we systematically review studies that evaluate complex interventions? PLoS Med 2009;6:e1000086. doi:10.1371/journal.pmed.1000086 PMID:19668360 57. Oakley A, Bonell C, Allen E, Stephenson J. Process evaluation in randomised controlled trials of complex interventions. BMJ 2006;332:413–6. doi:10.1136/bmj.332.7538.413 PMID:16484270 58. Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M.. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ 2008;337:a1655. doi:10.1136/bmj.a1655 PMID:18824488 59. Des Jarlais DC, Lyles C, Crepaz N. Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: the TREND statement. Am J Public Health 2004;94:361–6. doi:10.2105/ AJPH.94.3.361 PMID:14998794 Bull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771 684A Systematic reviews Insecticide-treated nets for malaria controlBarbara A Willey et al. Box 1. Ovid Medline search 1. (malaria* or severe malaria or plasmodium or Plasmodium falciparum or Plasmodium vivax).ot,tw,ab,fs,kw,ti,hw,nm. 2. Malaria/ or exp Malaria, Falciparum/ or Malaria, Cerebral/ or Malaria, Vivax/ 3. Plasmodium ovale/ or Plasmodium falciparum/ or Plasmodium/ or Plasmodium malariae/ or Plasmodium vivax/ 4. exp Anopheles/ 5. 1 or 2 or 3 or 4 6. Mosquito Control/ 7. Insect Vectors/ 8. “Bedding and Linens”/ 9. Mosquito Nets/ 10. Insecticide-Treated Bednets/ 11. exp Insecticides/ 12. exp Pyrethrins/ 13. DDT/ 14. Housing/ 15. Larva/ 16. exp Anopheles/ 17. exp Chemoprevention/ 18. Sulfadoxine/ 19. Pyrimethamine/ 20. pregnancy complications, infectious/ or pregnancy complications, parasitic/ 21. Infant/ 22. exp Anti-malarials/ 23. Diagnosis/ 24. exp Microscopy/ 25. exp Laboratories/ 26. Diagnostic Tests, Routine/ 27. Point-of-Care Systems/ 28. exp Therapeutics/ 29. exp Drug Therapy/ 30. Artemisinins/ 31. Amodiaquine/ 32. Mefloquine/ 33. exp Chloroquine/ 34. Primaquine/ 35. Insect Repellents/ 36. Community Health Aides/ 37. 6 or 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 38. (LLIN* or long-last* net or (long-lasting adj5 net)).ot,tw,ab,fs,kw,ti,hw,nm. 39. (ITN* or insecticide-treat* net or insecticidal-treat* net or insecticide-net or insecticidal-net or bed-net or bednet or treated-net or mosquito- net).ot,tw,ab,fs,kw,ti,hw,nm. 40. (IRS or indoor-residual spray* or indoor-spray*).ot,tw,ab,fs,kw,ti,hw,nm. 41. (larvicid* or larval control or larvi* fish or environment* management or environment* control* or drain* or house-screen* or (mosquito-proof* adj5 house) or repellent* or insecticide-treat* veil or insecticide-treat* hammock or insecticide-treat* blanket or insecticide-treat* cloth*). ot,tw,ab,fs,kw,ti,hw,nm. 42. (IPT or IPTp or IPTi or IPTc or intermittent preventive treatment*).ot,tw,ab,fs,kw,ti,hw,nm. 43. (diagnosis or RDT* or rapid diagnos* test* or rapid test* or microscop* or laborator*).ot,tw,ab,fs,kw,ti,hw,nm. 44. (treatment or antimalaria* or artemisinin-combination treat* or artemisinin-combination therap* or artemether lumefantrine or artesunate or amodiaquine or mefloquine or chloroquine or primaquine).ot,tw,ab,fs,kw,ti,hw,nm. 45. (malaria control or malaria intervention* or vector control* or vector management).ot,tw,ab,fs,kw,ti,hw,nm. 46. (community health worker* or village health worker* or (home manag* adj5 malaria)).ot,tw,ab,fs,kw,ti,hw,nm. 47. 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 48. 37 or 47 49. (scale-up or scaling-up or at-scale or go* to-scale or large-scale or roll-out or universal coverage).ot,tw,ab,fs,kw,ti,hw,nm. 50. 5 and 48 and 49 51. limit 50 to (humans and yr = ”2000 -Current”) Text word search fields: ot, original title; tw, title word; ab, abstract; fs, floating subheading; kw, key word; ti, title; hw, heading word; nm, name of substance word; * = truncation; exp, explode subject heading term. Bull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771684B Systematic reviews Insecticide-treated nets for malaria control Barbara A Willey et al. Ta bl e 1. Ch ar ac te ris tic s o f s tr at eg ie s t o de liv er in se ct ici de -t re at ed n et s ( IT Ns ) a t s ca le in a re as w ith e nd em ici ty fo r P la sm od iu m fa lci pa ru m a nd P la sm od iu m vi va x m al ar ia a Im pl em en ta tio n du ra tio n an d im pl em en te r Us er co st Fu ll su bs id y ( fr ee ) Pa rt ia l s ub sid y At co st Co nt in uo us Ro ut in e he al th s er vi ce s H ea lth fa ci lit y IT N to G P in 5 d ist ric ts (C hi pa ta , L un da zi , C ha m a, C ha di za , P et au ka ) o f Z am bi a2 1 An te na ta l c ar e an d/ or m at er na l a nd c hi ld h ea lth cl in ic LL IN to P W in 1 d ist ric t ( Ko ss i) of B ur ki na F as o2 2– 24 IT N to P W n at io na lly in E rit re a2 5 IT N to P W in 3 5 di st ric ts o f K en ya 26 LL IN to P W a nd c hi ld re n < 5 in 2 d ist ric ts (A dj um an i a nd Ji nj a) o f U ga nd a2 7 IT N to P W a nd c hi ld re n < 5 n at io na lly in K en ya 28 IT N o r v ou ch er to P W in 1 d ist ric t ( La w ra ) o f G ha na 29 ,3 0 Vo uc he r f or IT N to P W in 1 re gi on (V ol ta ) o f G ha na b, 31 Vo uc he r f or IT N to P W a nd c hi ld re n < 5 n at io na lly in th e U ni te d Re pu bl ic o f T an za ni ab ,3 2– 35 Vo uc he r f or IT N to P W in 2 d ist ric ts (K ilo m be ro a nd U la ng a) in th e U ni te d Re pu bl ic o f Ta nz an ia b, 36 –3 8 IT N to P W a nd c hi ld re n < 5 n at io na lly in M al aw i3,3 9, 40 Re ta il IT N (v ia v ou ch er ) t o PW in 1 d ist ric t ( La w ra ) o f G ha na 29 ,3 0 IT N (v ia v ou ch er ) t o PW in 1 re gi on (V ol ta ) o f G ha na 31 IT N (v ia v ou ch er ) t o PW a nd c hi ld re n < 5 n at io na lly in th e U ni te d Re pu bl ic o f Ta nz an ia 32 –3 5 LL IN to G P in 1 d ist ric t ( Ko ss i) of B ur ki na F as o2 2– 24 IT N to G P na tio na lly in K en ya 28 IT N to G P in 2 d ist ric ts (K ilo m be ro a nd U la ng a) o f t he U ni te d Re pu bl ic o f T an za ni a3 6– 38 Co m m un it y IT N to G P na tio na lly in E rit re a af te r 2 00 32 5 IT N to G P na tio na lly in M al aw i a fte r 2 00 33 ,3 9, 40 IT N to G P in 5 d ist ric ts (C hi pa ta , L un da zi , C ha m a, C ha di za , P et au ka ) o f Z am bi a2 1 IT N to G P na tio na lly in Er itr ea b ef or e 20 03 25 Ti m e- lim ite d St an d- al on e ca m pa ig n LL IN to c hi ld re n < 5 in 2 d ist ric ts (M ic he w en i a nd N or th A ) i n Za nz ib ar 41 LL IN to P W a nd c hi ld re n < 5 in 2 d ist ric ts (A dj um an i a nd Ji nj a) o f U ga nd a2 7 Ca m pa ig n in te gr at ed w it h pu bl ic h ea lt h ca m pa ig n M ea sle s v ac ci na tio n IT N /L LI N to c hi ld re n < 5 in 1 d ist ric t ( La w ra ) o f G ha na 29 ,3 0 LL IN to c hi ld re n < 5 in 4 d ist ric ts (K w al e, B on do , G re at er K isi i, M ak ue ni ) o f K en ya 42 ,4 3 LL IN to c hi ld re n < 5 in 5 9 di st ric ts o f M ad ag as ca r44 IT N to c hi ld re n < 5 in re gi on (L in di ) o f t he U ni te d Re pu bl ic o f T an za ni a4 5 IT N to c hi ld re n < 5 in 1 d ist ric t ( Ri fij i) of th e U ni te d Re pu bl ic o f T an za ni a4 6 LL IN to c hi ld re n < 5 n at io na lly in To go 47 ,4 8 LL IN to c hi ld re n < 5 in 4 ru ra l d ist ric ts (C hi lu bi , K ap ut a, M am bw e, N yi m ba ) o f Za m bi a4 9 Vo uc he r f or IT N to c hi ld re n < 5 in 1 u rb an d ist ric t ( Ka la lu sh i) of Z am bi a4 9 Po lio v ac ci na tio n LL IN to c hi ld re n < 5 n at io na lly in N ig er 50 M DA fo r l ym ph at ic fi la ria sis IT N to P W a nd c hi ld re n < 5 in 2 d ist ric ts (K an ke , A kw an ga ) o f N ig er ia 51 GP , g en er al p op ul at io n; L LI N , lo ng -la st in g in se ct ic id al n et s; M DA , m as s d ru g ad m in ist ra tio n; P W , p re gn an t w om en . a S tu di es m ay a pp ea r i n m or e th an o ne c at eg or y if m ul tip le st ra te gi es w er e us ed to d el iv er IT N s a t s ca le o r i f s tra te gi es c ha ng ed o ve r t im e. b U se d vo uc he r-b as ed d ist rib ut io n of p ar tia lly su bs id ise d IT N s, in w hi ch v ou ch er s w er e di st rib ut ed in a nt en at al c ar e cl in ic s a nd e xc ha ng ed fo r a p ar tia lly su bs id ise d IT N in re ta il ou tle ts . Bull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771 684C Barbara A Willey et al. Systematic reviews Insecticide-treated nets for malaria control Ta bl e 2. Su m m ar y o f 2 0 st ud ie s o n th e de liv er y o f i ns ec tic id e- tr ea te d ne ts (I TN s) a t s ca le in a re as w ith e nd em ici ty fo r P la sm od iu m fa lci pa ru m a nd P la sm od iu m vi va x, b y d el iv er y s tr at eg ya De liv er y s tr at eg y Co un tr y, sc al e Ev al ua tio n m et ho d Ou tc om e Eq ui ty In di ca to r Ou tc om eb Co nt in uo us Fu ll su bs id y; ro ut in e he al th se rv ic es (A N C cl in ic ) a nd /o r co m m un it y- ba se d AN C cl in ic s t o PW (f re e) a nd re ta il to GP (p ar tia l s ub sid y) , i m pl em en te d 20 06 in 2 4 he al th c en tre c at ch m en t ar ea s Bu rk in a Fa so , 1 d ist ric t (K os si) 22 –2 4 cR CT o f S M v er su s S M a nd A N C di st rib ut io n vi a H H su rv ey s i n 20 07 (1 04 9 H H ) Co m pa ris on a re a: H H L LI N o w ne rs hi p, 2 3% ; s oc ia l m ar ke tin g on ly In te rv en tio n ar ea : H H L LI N o w ne rs hi p, 3 5% ; S M a nd AN C; P < 0 .0 01 N ot re po rt ed N ot re po rt ed Fr om 2 00 1, A N C cl in ic s t o PW (f re e) an d H F an d CH W to G P (fu ll co st ; fre e af te r 2 00 3) Er itr ea , n at io na l25 20 04 N M CP su rv ey in 4 o f 6 re gi on s; un co nt ro lle d cr os s- se ct io na l s tu dy c H H IT N o w ne rs hi p, 6 2% ; I TN u se a m on g ch ild re n < 5 , 59 % N ot re po rt ed N ot re po rt ed AN C cl in ic s t o PW (f re e in A dj um an i on ly ) a nd st an d- al on e ne t c am pa ig n to c hi ld re n < 5 (f re e in b ot h di st ric ts ) in 2 00 7 U ga nd a, 2 d ist ric ts (A dj um an i, Jin ja )27 H H su rv ey in 2 00 7 (3 78 H H in th e AN C st ud y) ; n o co nt ro ld IT N u se a m on g ch ild re n < 5 , 9 4% (A N C st ud y: Ad ju m an i) N ot re po rt ed N ot re po rt ed Pa rt ia l s ub si dy ; r ou ti ne h ea lt h se rv ic es (H Fs ; A N C an d/ or M CH cl in ic s) a nd /o r r et ai le rs a nd /o r co m m un it y- ba se d Fr om 2 00 2, A N C cl in ic s t o PW (p ar tia l s ub sid y vi a vo uc he r); th is fo llo w ed a n in te gr at ed c am pa ig n to ch ild re n < 5 (f re e) e ar lie r i n 20 02 Gh an a, 1 d ist ric t (L aw ra )29 ,3 0 H H su rv ey in 2 00 6 (4 75 H H , 6 74 ch ild re n < 5 ); un co nt ro lle d cr os s- se ct io na l s tu dy Af te r c am pa ig n an d AN C de liv er y, 20 06 : H H IT N ow ne rs hi p, 7 4% ; I TN u se a m on g ch ild re n < 5 , 6 0% H H a ss et in de x; eq ui ty ra tio H ou se ho ld IT N o w ne rs hi p: e qu ity ra tio , 0 .9 5; IT N u se a m on g ch ild re n < 5 : e qu ity ra tio , 1 .0 8 Fr om 2 00 0, re ta il to G P; a fte r 2 00 4, M CH c lin ic s t o PW a nd c hi ld re n < 5 in ru ra l a re as (p ar tia l s ub sid y) Ke ny a, n at io na l28 N at io na l s ur ve y in 2 00 3; m on ito rin g of n et sa le s f or M CH sa le s i n 20 05 c 20 03 : H H IT N o w ne rs hi p, 3 1% ; 2 4% IT N u se in < 5 , 2 4% ; 20 05 : 9 0% o f I TN s s ol d vi a M CH U rb an /r ur al re sid en ce 20 03 H H su rv ey : I TN u se a m on g ch ild re n < 5 o f 5 1% in u rb an a re as an d 17 % in ru ra l a re as Fr om 2 00 2, M CH c lin ic s t o PW a nd ch ild re n < 5 ; a fte r 2 00 3, to G P by co m m un ity -b as ed g ro up s ( pa rt ia l su bs id y) M al aw i, na tio na l3,3 9, 40 D H S in 2 00 0 an d 20 04 c Be fo re c am pa ig n, 2 00 0: H H IT N o w ne rs hi p, 1 3% ; I TN us e am on g ch ild re n < 5 , 8 % Af te r c am pa ig n, 2 00 4: H H IT N o w ne rs hi p, 4 3% ; I TN u se am on g ch ild re n < 5 , 3 8% N ot re po rt ed N ot re po rt ed Fr om 1 99 7, H F, co m m un ity -b as ed an d re ta ile rs to G P (p ar tia l s ub sid y) U ni te d Re pu bl ic of Ta nz an ia , 2 di st ric ts (K ilo m be ro , U la ng a) 36 –3 8 D em og ra ph ic S ur ve ill an ce Sy st em in 1 99 7 (1 0 31 3 H H , 2 40 ch ild re n < 2 ), 19 98 (6 46 c hi ld re n < 1 ), 20 00 (1 01 c hi ld re n < 1 ); cl us te r s ur ve y in 1 99 9 (7 57 H H w ith c hi ld re n < 5 ) Be fo re c am pa ig n, 1 99 7: H H IT N o w ne rs hi p, 3 7% ; IT N u se a m on g ch ild re n < 2 , 1 0% Af te r c am pa ig n, 1 99 8: IT N u se a m on g ch ild re n < 1 , 45 % ; 2 00 0: IT N u se a m on g ch ild re n < 1 , 5 4% ; 19 99 : I TN u se a m on g ch ild re n < 5 , 1 8% N ot re po rt ed N ot re po rt ed (c on tin ue s. . . ) Bull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771684D Systematic reviews Insecticide-treated nets for malaria control Barbara A Willey et al. De liv er y s tr at eg y Co un tr y, sc al e Ev al ua tio n m et ho d Ou tc om e Eq ui ty In di ca to r Ou tc om eb Fr om 2 00 4, A N C cl in ic s t o PW (p ar tia l s ub sid y vi a vo uc he r a t re ta ile r) U ni te d Re pu bl ic o f Ta nz an ia , n at io na l32 –3 5 H H su rv ey in 2 00 5 (6 19 9 H H , 55 67 c hi ld re n < 5 ), 20 06 (6 26 0 H H , 5 81 5 ch ild re n < 5 ), 20 07 (6 19 8 H H , 6 18 6 ch ild re n < 5 ) H H IT N o w ne rs hi p, 1 8% in 2 00 5, 2 9% in 2 00 6 an d 36 % in 2 00 7; IT N u se a m on g ch ild re n < 5 , 1 2% in 2 00 5, 2 1% in 2 00 6 an d 26 % in 2 00 7 As se t i nd ex IT N u se a m on g ch ild re n < 5 ; e qu ity ra tio , 0 .1 1 in 2 00 5 an d 0. 29 in 2 00 7 H F an d co m m un ity v ol un te er s t o GP (p ar tia l s ub sid y) fr om 1 99 8 in 3 in te rv en tio n di st ric ts Za m bi a, 5 d ist ric ts (C hi pa ta , L un da zi , Ch am a, C ha di za , Pe ta uk a) 21 Q ua si- ex pe rim en ta l s tu dy (n on ra nd om ize d) , H H su rv ey in 2 00 0 (2 98 6) Co m pa ris on d ist ric ts : H H IT N o w ne rs hi p, 1 .3 % In te rv en tio n di st ric ts : H H IT N o w ne rs hi p, 1 4% ; P < 0 .0 01 As se t i nd ex Co m pa ris on d ist ric ts : c on ce nt ra tio n in de x of H H IT N o w ne rs hi p, 0 .7 1 In te rv en tio n di st ric ts : c on ce nt ra tio n in de x of H H IT N o w ne rs hi p, 0 .3 4 Ti m e- lim ite d Fu ll su bs id y (f re e) ; s ta nd -a lo ne ca m pa ig n AN C cl in ic s t o PW (f re e) a nd st an d- al on e ne t c am pa ig n to c hi ld re n < 5 (fr ee ) i n 20 07 U ga nd a, 2 d ist ric ts (A dj um an i, Jin ja )27 H H su rv ey in 2 00 7 (A dj um an i: 52 0 H H ; J in ja : 5 47 H H ); un co nt ro lle d cr os s- se ct io na l s tu dy d Af te r c am pa ig n: IT N u se a m on g ch ild re n < 5 , 9 3% in Ad ju m an i a nd 5 6% in Ji nj a As se t i nd ex IT N u se a m on g ch ild re n un de r 5 : co nc en tra tio n in de x, 0 .0 8 IT N o nl y ca m pa ig n to c hi ld re n < 5 an d PW (f re e) 2 00 5– 20 06 Za nz ib ar , 2 d ist ric ts (M ic he w en i, N or th A )41 H H su rv ey in 2 00 6 (M ic he w en i: 24 5 H H , 3 80 c hi ld re n < 5 ; N or th A: 2 64 H H , 3 89 c hi ld re n < 5 ); un co nt ro lle d cr os s- se ct io na l st ud y Af te r c am pa ig n, 2 00 6: IT N u se in c hi ld re n < 5 , 5 7% in M ic he w en i a nd 8 7% in N or th A As se t i nd ex IT N u se a m on g ch ild re n un de r 5 : eq ui ty ra tio , 1 in N or th A a nd 0 .6 9 in M ic he w en i Fu ll su bs id y (f re e) ; i nt eg ra te d w it h pu bl ic h ea lt h ca m pa ig n D ist rib ut io n in te gr at ed w ith m ea sle s va cc in at io n ca m pa ig n to c hi ld re n < 5 (f re e) in 2 00 2 an d AN C to P W (p ar tia l s ub sid y vi a vo uc he r) la te r in 2 00 2 Gh an a, 1 d ist ric t (L aw ra )29 ,3 0 H H su rv ey in 2 00 3 (4 75 H H , 6 74 ch ild re n < 5 ) ( un co nt ro lle d cr os s- se ct io na l s tu dy ) Af te r c am pa ig n, 2 00 3: H H IT N o w ne rs hi p, 9 0% ; I TN u se am on g ch ild re n < 5 , 6 0% H H a ss et in de x IT N u se a m on g ch ild re n < 5 : e qu ity ra tio , 1 (s im ila r a cr os s q ui nt ile s) D ist rib ut io n in te gr at ed w ith m ea sle s va cc in at io n ca m pa ig n to c hi ld re n < 5 (f re e) in 2 00 6 Ke ny a, 4 d ist ric ts (K w al e, B on do , G re at er Ki sii , M ak ue ni )42 ,4 3 Be fo re -a nd -a fte r s ur ve y in 2 00 4 (2 68 7 H H , 3 71 9 ch ild re n < 5 ), 20 06 (2 58 9 H H , 3 25 7 ch ild re n < 5 ) Be fo re c am pa ig n, 2 00 4: H H IT N o w ne rs hi p, 2 4. 5% ; I TN us e am on g ch ild re n < 5 , 7 % Af te r c am pa ig n, 2 00 6: H H IT N o w ne rs hi p, 7 9% ; I TN u se am on g ch ild re n < 5 , 6 7% As se t i nd ex H H IT N o w ne rs hi p in 2 00 6: e qu ity ra tio , 1 .1 (e qu al a cr os s q ui nt ile s) v . 1. 2 in 2 00 4. D ist rib ut io n in te gr at ed w ith m ea sle s va cc in at io n ca m pa ig n to c hi ld re n < 5 (f re e) in 2 00 7 M ad ag as ca r, 59 di st ric ts 44 H H su rv ey in 2 00 8 (2 86 0 H H , 23 69 c hi ld re n < 5 ); un co nt ro lle d cr os s- se ct io na l s tu dy Af te r c am pa ig n, 2 00 8: H H L LI N o w ne rs hi p, 7 7% ; L LI N us e am on g ch ild re n < 5 , 8 1% As se t i nd ex H H L LI N o w ne rs hi p: e qu ity ra tio , 1. 05 D ist rib ut io n in te gr at ed w ith p ol io va cc in at io n ca m pa ig n to c hi ld re n < 5 (f re e) in 2 00 5 an d 20 06 N ig er , n at io na l50 H H su rv ey in 2 00 6 (2 45 0 H H ); un co nt ro lle d cr os s- se ct io na l st ud yd Af te r c am pa ig n, 2 00 6: H H IT N o w ne rs hi p, 6 5% ; I TN u se am on g ch ild re n < 5 , 5 6% As se t i nd ex H H IT N o w ne rs hi p: e qu ity ra tio , 0. 79 (c on tin ue s. . . ) ( . . . c on tin ue d) Barbara A Willey et al. 684EBull World Health Organ 2012;90:672–684E | doi:10.2471/BLT.11.094771 Systematic reviews Insecticide-treated nets for malaria control De liv er y s tr at eg y Co un tr y, sc al e Ev al ua tio n m et ho d Ou tc om e Eq ui ty In di ca to r Ou tc om eb D ist rib ut io n in te gr at ed w ith M DA fo r L F ca m pa ig n to P W a nd c hi ld re n < 5 (f re e) in 2 00 4 N ig er ia , 2 d ist ric ts (K an ke , A kw an ga )51 H H su rv ey in 2 00 5 (2 90 H H , 4 73 ch ild re n < 5 ); un co nt ro lle d cr os s- se ct io na l s tu dy Af te r c am pa ig n, 2 00 5: H H IT N o w ne rs hi p, 7 4% ; I TN u se am on g ch ild re n < 5 , 3 9% N ot re po rt ed N ot re po rt ed D ist rib ut io n in te gr at ed w ith m ea sle s va cc in at io n ca m pa ig n to c hi ld re n < 5 (f re e) in 2 00 4 To go , n at io na l47 ,4 8 Be fo re -a nd -a fte r s ur ve y in 3 di st ric ts in 2 00 4 (Y ot o: 4 95 H H , 71 8 ch ild re n < 5 ; O go u: 5 64 H H , 79 8 ch ild re n < 5 ; T on e: 6 45 H H , ch ild re n < 5 ), 20 05 (Y ot o, 6 48 H H , 99 8 ch ild re n < 5 ; O go u: 5 94 H H , 89 3 ch ild re n < 5 ; T on e: 5 86 H H , 92 2 ch ild re n < 5 ) Be fo re c am pa ig n, 2 00 4: H H IT N o w ne rs hi p, < 1 % in 3 su rv ey ed d ist ric ts (Y ot o, O go u an d To ne ) Af te r c am pa ig n, 2 00 5: H H IT N o w ne rs hi p, 5 5% , 5 9% 70 % in Yo to , O go u an d To ne , r es pe ct iv el y; IT N u se am on g ch ild re n < 5 , 3 6% , 4 4% a nd 8 1% in Yo to , O go u an d To ne , r es pe ct iv el y As se t i nd ex H H IT N o w ne rs hi p in 2 00 5: eq ui ty ra tio , 1 .0 0, 1 .3 1 an d 1. 05 in Yo to , O go u an d To ne d ist ric ts , re sp ec tiv el y; 2 00 4: e qu ity ra tio , n ot av ai la bl e D ist rib ut io n in te gr at ed w ith m ea sle s va cc in at io n ca m pa ig n to c hi ld re n < 5 (f re e) in 2 00 5 U ni te d Re pu bl ic o f Ta nz an ia , 1 re gi on (L in di )45 H H su rv ey in 2 00 5 (5 74 H H , 3 54 ch ild re n < 5 ); un co nt ro lle d cr os s- se ct io na l s tu dy Af te r c am pa ig n, 2 00 5: H H IT N o w ne rs hi p, 3 7% ; I TN u se am on g ch ild re n < 5 , 2 1. 5% As se t i nd ex H H IT N o w ne rs hi p eq ui ty ra tio , 0 .8 6 D ist rib ut io n in te gr at ed w ith m ea sle s va cc in at io n ca m pa ig n to c hi ld re n < 5 (f re e) a nd A N C to P W (p ar tia l su bs id y vi a vo uc he r a t r et ai le r) in 20 04 –2 00 5 U ni te d Re pu bl ic o f Ta nz an ia , 1 d ist ric t (R ufi ji) 46 H H su rv ey in 2 00 6 (1 75 2 H H , 7 32 ch ild re n < 5 ); un co nt ro lle d cr os s- se ct io na l s tu dy Af te r c am pa ig n, 2 00 6: IT N u se a m on g ch ild re n < 5 , 40 % As se t i nd ex O ve ra ll H H IT N o w ne rs hi p: co nc en tra tio n in de x, 0 .1 3; fr ee n et s ca m pa ig n: c on ce nt ra tio n in de x, 0. 02 D ist rib ut io n in te gr at ed w ith m ea sle s va cc in at io n ca m pa ig n to c hi ld re n < 5 (f re e) in 2 00 3 Za m bi a, 5 d ist ric ts (C hi lu bi , K ap ut a, M am bw e, N yi m ba , Ka la lu sh i)4 9 H H su rv ey in 2 00 3 (1 70 5 ru ra l H H , 3 69 u rb an H H ); un co nt ro lle d cr os s- se ct io na l s tu dy e Af te r c am pa ig n, 2 00 3: H H IT N o w ne rs hi p, 8 8% in ru ra l ar ea s a nd 8 2% in u rb an a re as ; I TN u se a m on g ch ild re n < 5 , 5 6% in ru ra l a re as a nd 7 7% in u rb an a re as As se t i nd ex H H IT N o w ne rs hi p: e qu ity ra tio , 0. 88 in ru ra l a re as a nd 1 .1 9 in u rb an ar ea s AN C, a nt en at al c ar e; C HW , c om m un ity h ea lth w or ke r; cR CT , c lu st er ra nd om ize d co nt ro lle d tri al ; D HS , d em og ra ph ic a nd h ea lth su rv ey ; G P, ge ne ra l p op ul at io n; H F, he al th fa ci lit y; H H, h ou se ho ld ; L F, ly m ph at ic fi la ria sis ; L LI N , lo ng -la st in g in se ct ic id al ne ts ; M CH , m at er na l a nd c hi ld h ea lth ; M DA , m as s d ru g ad m in ist ra tio n; N M CP , n at io na l m al ar ia c on tro l p ro gr am m e; P W , p re gn an t w om en ; S M , s oc ia l m ar ke tin g. a S tu di es m ay a pp ea r i n m or e th an o ne c at eg or y if m ul tip le st ra te gi es w er e us ed to d el iv er IT N s a t s ca le o r i f s tra te gi es c ha ng ed o ve r t im e. b F or c on ce nt ra tio n in de xe s, va lu es o f 0 in di ca te e qu ita bl e di st rib ut io n; v al ue s > 0 in di ca te in eq ui ta bl e di st rib ut io n be ne fit in g th e le as t p oo r g ro up . F or e qu ity ra tio s, va lu es o f 1 in di ca te e qu ita bl e di st rib ut io n; ra tio s > 1 su gg es t t ha t t he p oo re st qu in til es w er e fa vo ur ed . c T ot al n o. o f h ou se ho ld s i nc lu de d in th e st ud y w as n ot re po rte d. d T ot al n o. o f c hi ld re n un de r 5 in cl ud ed in th e st ud y w as n ot re po rte d. e D en om in at or s f or h ou se ho ld s a nd c hi ld re n un de r 5 a re e qu al b ec au se th e in de x ch ild (i .e . y ou ng es t c hi ld in h ou se ho ld w ho w as a ge d ≥ 6 m on th s a t t im e of th e ca m pa ig n) w as in cl ud ed in th e ca lc ul at io n. ( . . . c on tin ue d)