Sustaining Fragile Gains: The Need to Maintain Coverage with Long-Lasting Insecticidal Nets for Malaria Control and Likely Implications of Not Doing So

Abstract

Global commitment to malaria control has greatly increased over the last decade. Long-lasting insecticidal nets (LLINs) have become a core intervention of national malaria control strategies and over 450 million nets were distributed in sub-Saharan Africa between 2008 and 2012. Despite the impressive gains made as a result of increased investment in to malaria control, such gains remain fragile. Existing funding commitments for LLINs in the pipeline to 2016 were collated for 40 sub-Saharan African countries. The population-based model NetCALC was used to estimate the potential LLIN coverage achievable with these commitments and identify remaining gaps, and the Lives Saved Tool (LiST) was used to estimate likely consequences for mortality impact if these gaps remain unfilled. Overall, countries calculated a total need of 806 million LLINs for 2013-16. Current funding commitments meet just over half of this need, leaving approximately 374 million LLINs unfunded, most of which are needed to maintain coverage in 2015 and 2016. An estimated additional 938,500 child lives (uncertainty range: 559,400–1,364,200) could be saved from 2013 through 2016 with existing funding (relative to 2009 LLIN coverage taken as the ‘baseline’ for this analysis); if the funding gap were closed this would increase to 1,180,500 lives saved (uncertainty range: 707,000–1,718,900). Overall, the funding gap equates to approximately 242,000 avoidable malaria-attributable deaths amongst under-fives. Substantial additional resources will need to be mobilized to meet the full LLIN need of sub-Saharan countries to maintain universal coverage. Unless these resources are mobilized, the impressive gains made to date will not be sustained and tens of thousands of avoidable child deaths will occur.

Prioritizing Pregnant Women for Long-Lasting Insecticide Treated Nets through Antenatal Care Clinics

“…Notwithstanding, funding for malaria control peaked at $US2 billion in 2011 [43] and has begun to decline, ushering in an era of limited resources. Amidst the push to achieve universal coverage and dwindling resources, there is the potential danger whereby “keep-up” strategies lose resources and funding to its more attractive “catch-up” counterpart.…”

Analysing the nutrition-disease nexus: the case of malaria

“…Eleven scenarios are considered that span a range of baseline ITN coverage values and EIR values. Although spatial targeting should cause these two quantities to be positively correlated in practice, the large funding gap in ITNs [ 10 ] suggests that the only coverage-EIR combination considered here that may be rare in practice is the 80 % coverage, EIR = 10 scenario.…”

“…Although ITNs are effective at preventing malaria [ 6 ], demand is highly price-sensitive and is greatly reduced when ITNs are not free [ 7 , 8 ], making them attractive candidates for free targeted intervention. The World Health Organization recommended a switch from targeted ITN intervention (e.g., for children under five and pregnant women) to universal ITN coverage in 2008 [ 9 ], which led to the distribution of over 450M ITNs in sub-Saharan Africa between 2008 and 2012 [ 10 ]. Nonethless, malaria control funding peaked in 2012 and has begun to decline, with funding commitments in 2013–2016 estimated to meet just over half of demand, yielding a funding gap of 374M ITNs [ 10 ].…”

“…The World Health Organization recommended a switch from targeted ITN intervention (e.g., for children under five and pregnant women) to universal ITN coverage in 2008 [ 9 ], which led to the distribution of over 450M ITNs in sub-Saharan Africa between 2008 and 2012 [ 10 ]. Nonethless, malaria control funding peaked in 2012 and has begun to decline, with funding commitments in 2013–2016 estimated to meet just over half of demand, yielding a funding gap of 374M ITNs [ 10 ]. In this resource-constrained setting, the targeting of ITNs may need to be reconsidered [ 11 ].…”

Costs of insecticide-treated bed net distribution systems in sub-Saharan Africa

“…While mass distributions are a cost-effective way to quickly achieve high coverage over a particular area, coverage gaps begin to appear almost immediately postdistribution through net deterioration, loss of nets, and population growth, therefore, requiring complementary continuous distribution channels to sustain or "keep up" coverage over time [8,[26][27][28]. Models have suggested that relying solely on mass distributions without keeping up access through health facility-based systemsthrough ANC and EPI (sometimes also called "routine distribution") would result in lower levels of access [29].…”