Insecticide Treated Nets in Malawi: Lessons from the 2015-16 Demographic and Health Survey

In 2000 the Abuja Declaration set a target of 80% coverage for people in endemic countries owning AND sleeping under nets by the year 2010. The United Nations came along in 2009 and upped the ante making the target “Universal Coverage.” Such targets were assumed to help countries meet the 2015 Millennium Development Goals for reducing malaria morbidity and mortality. So what happens when these dates pass and countries still have neither achieved nor maintained ITN coverage?

An example of the remaining challenges can be seen in the 2015-16 malaria section of the Malawi Demographic and Health Survey. The MDHS notes that while household ownership of nets increased from 27% in 2004 to 57% in 2010, it did not change between 2010 and 2015-16. This is despite efforts by the Ministry of health, The US President’s Malaria Initiative and the Global Fund, not to mention peer pressure from the members of the Southern African Development Community who are pushing a malaria elimination agenda.

Even though the actual availability of nets in the households did not increase recently, use or those available improved slightly. The MDHS explains that, “The ITN use among children under age 5 has increased over the years, from 15% in 2004 to 39% in 2010, and 43% in 2015-16. Among pregnant women, ITN use increased from 15% in 2004 to 35% in 2010, and 44% in 2015-16.” This shows some improvement in health education activities, but people cannot use the net that is not available.

Where do the nets come from? Among the nets found in surveyed households newly a third (32%) were acquired through a mass distribution campaign. Nearly half (47%) were acquired through a routine clinic visit such as antenatal care, child birth, immunization clinic and other clinic visits. The remainder were bought from shops or other places. This shows a good mix of distribution strategies. It is therefore, the volume of nets made available that is of concern, possibly more than the process, but further analysis by the national malaria program should examine all of these avenues to ensure efficiency.

An irony appears in the pie chart on net availability in households.  While 43% did not have any nets, another 33% did not have enough nets to meet coverage targets of one net per two people. This again poses serious access issues. Thus, it is not surprising that 13% of people who in theory have access to nets did not sleep under them.

Several other challenges were documented. Only 45% of the poorest segment of the population lived in households with nets, compared to 69% of the wealthiest. Similarly rural populations were less likely to sleep under ITNs (32%) than urban (42%). It would appear that more attention to equity in ITN programs is needed. Interestingly, urban households are more likely to purchase their nets from shops and markets than rural dwellers.

Good news is that the US President’s Malaria Initiative plans to help maintain coverage of pregnant women and children in the coming year through the procurement and distribution of ITNs through routine service channels with 1.2 million ITNs. In addition the Global Fund reports that over 7.7 million ITNs were distributed in Malawi in 2016 with it’s support.  Maybe these efforts will reflect in the next iteration of the DHS or MIS, but fluctuations in ITN availability do impact on disease transmission, and concerns about equity will remain.

The DHS and its sister survey, the Malaria Information Surveys are crucial tools for identifying challenges and planning ways to improve coverage of malaria interventions. Hopefully Malawi will be able to use this information to save lives.

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