Review of surveys from 15 countries shows that, “Within ITN-owning households, many children and pregnant women are still not using them. Between-country analysis with linear regression showed child ITN use increases as intra-household access to ITNs increases,” according to Eisele and colleagues. They note further that –
Results from within-country logistic regression analyses were consistent with between-country analysis showing intra-household access to ITNs is the strongest and most consistent determinant of use among children. The gaps in ITN use and possession will likely persist in the absence of achieving a ratio of no more than two people per ITN.
The Roll Back Malaria Partnership asserts that, “To achieve universal coverage, countries must go beyond the procurement and financing of interventions to ensure that the products can reach every person at risk.” Calls for universal coverage have been simplified to two nets per household.
Many households in Africa contain between 5-6 people. Are two nets enough to ensure vulnerable groups are covered? If one generously estimates the population of pregnant women and children under fiver years of age to be 25%, then yes, two nets may suffice. But what really happens in terms of intrahousehold allocation of valuable resources?
Again Eisele et al. suggest that, “Countries should aim to achieve greater than one ITN per household to ensure adequate intra-household access for children and pregnant women.” They realized that having a net does not guarantee its use, but the more nets there are in a household, the greater likelihood that vulnerable groups have a chance at being protected. Specifically they recommend that –
Once intra-household access to ITNs is attained, the remaining gap between ITN use among children and pregnant women within households possessing them may be minimized further with behavior change communication campaigns.
BCC alone will not solve the problem – communities must be actively involved in their own net distribution and use promotion programs.