(June 2006) Malaria is one of the most lethal diseases in sub-Saharan Africa—responsible for 9 percent of deaths annually and the second-highest burden of disease behind AIDS.1 And malaria is the leading killer of African children under age 5, causing about 18 percent of all deaths (803,000 per year) in that age group.2 Unfortunately, the rapid spread of resistance to antimalarial drugs, widespread poverty, and weak health infrastructure throughout Africa means that the burden from malaria in African countries continues to rise.

While malaria treatment remains a high priority in Africa, effective prevention techniques are available that could—if made widely accessible—vastly improve the health profile of Africa’s children and pregnant women:

  • Insecticide-treated bednets (ITNs) are the current “best buy” for governments in developing countries where malaria is common.3 ITNs are inexpensive and easy to use, but thus far have not reached the recommended coverage level to fulfill their potential as a prevention tool. Increasing the coverage of ITNs among vulnerable populations is perhaps one of the most important mechanisms for effective malaria control
  • Intermittent preventive therapy (IPT), drugs given in the second and third trimester to pregnant women, often complements ITNs in national prevention programs.4
  • Indoor residual spraying is another way to control mosquitoes by spraying the inside of people’s houses with long-lasting insecticide. Indoor spraying is particularly effective in dense urban settings and where there is a strong delivery system.5

On April 25, Africans celebrated Africa Malaria Day, reaffirming a continental commitment to surmount the mosquito-borne disease. This commitment—conceived six years ago in the Abuja Declaration—sets targets for providing prompt and effective treatment as well as prevention tools such as ITNs and indoor spraying to 60 percent of the people at highest risk of malaria (young children and pregnant women).6

However, challenges to implementing effective prevention programs on the ground are vast. Delivery of ITNs is likely to be sporadic if the public health system is weak. Rural and poor people have little access to ITNs, which are available in urban markets at a price. And nets are sometimes torn or have not been re-treated with insecticide. Overcoming these challenges will safeguard the lives of thousands of African children.

Malaria Burden in Sub-Saharan Africa

Despite international and Africa-wide commitments to battle malaria, the disease is still widespread on the continent. Up to 90 percent of all malaria deaths occur in tropical Africa.7 In sub-Saharan Africa, malaria is endemic in 50 countries, with the greatest number of cases occurring in Nigeria, the Democratic Republic of the Congo, Tanzania, and Ethiopia.8

In endemic areas, children under age 5 (who have not yet acquired immunity) and pregnant women whose immunity is temporarily impaired) are at highest risk for contracting the disease. Indeed, of the more than 1 million Africans who die from malaria each year, most are children under age 5.9 Malaria is also a significant indirect cause of infant death: Malaria-related maternal anemia during pregnancy, low birth weight, and premature delivery is estimated to cause 75,000 to 200,000 infant deaths per year in sub-Saharan Africa.10

Moreover, the cost of malaria prevention is high for families and individuals, who may spend up to 25 percent of their annual income on prevention and treatment. And in countries with a heavy malaria burden (where the disease accounts for up to one-half of all hospital admissions and outpatient visits), government expenditures related to the disease may add up to 40 percent of spending on public health.11

The Abuja targets are in line with the Millennium Development Goal of halting and beginning to reverse by 2015 the incidence rates of malaria.12 However, few African countries are likely to reach these targets because, until very recently, disease-control efforts remained too fragmented and major international investment had come too late.

Cost-Effective Solutions Are Available

But effective interventions against malaria don’t cost a lot. Recently, the Disease Control Priorities Project (DCPP) released new information that shows three preventive interventions to be highly cost-effective—ITNs, indoor spraying, and IPT to prevent malaria during pregnancy.13 According to DCPP, the total cost of a program to promote ITN use for children is about $2.80 per capita per year, and a program for indoor spraying about $4.00 per capita per year.14

Roll Back Malaria (RBM), a joint partnership of UN agencies and malaria-affected countries, recommends using ITNs over spraying in malaria-endemic countries for a number of reasons:

  • Systems needed for large-scale spraying in rural areas do not exist.
  • ITNs allow vector-control resources to be targeted toward those most at risk.
  • ITNs protect those who use them as well as those without nets in nearby houses.
  • ITN protection is longer in duration than spraying because a net gives significant protection even after the insecticide has worn off.15

Indeed, according to RBM, the number of nets distributed in more than 14 African countries has increased 10-fold since 2002. Subsidized or free-of-charge ITN distribution has proved successful in increasing coverage of the most vulnerable populations—children under age 5 and pregnant women—often by being linked to antenatal care or national child immunization programs.

What Prevents a Country From Reaching Universal Coverage?

Table 1
Proportion of Children Under Age 5 Sleeping Under ITNs, Selected African Countries

ITN Coverage

Source: World Malaria Report 2005 (2005).

ITNs have been shown to reduce deaths in young children by an average of 20 percent, but increasing coverage is not an easy task.16 Even with cost-effective interventions, more than 95 percent of children in malaria-endemic regions of sub-Saharan Africa are not using ITNs.17 In general, the cost of an ITN is a major barrier to ownership and usage. Rural and poorer households—where people are at higher risk of malaria—thus have less access to ITNs than urban and relatively wealthy households, which are more likely to own ITNs. Table 1 shows that even countries such as Malawi, where ITN distribution efforts have been stepped up, still have low ITN coverage of children under age 5.

Two primary objectives guide policy and programming regarding ITN distribution—universal coverage and sustainability. While these objectives are not mutually exclusive, advocates who prioritize sustainability argue that developing local markets for ITNs—thus increasing both supply and demand—will better guarantee long-term usage. The issue of net quality must also be considered, as cheaper quality nets are more likely to tear.

In most cases, the best way to achieve universal coverage of ITNs is free distribution of nets to as many people as possible. Several countries have undertaken free distribution schemes to rapidly increase ITN coverage— Eritrea, Ghana, Nigeria, Togo, and Zambia.

In Togo, a national campaign of ITN distribution accompanied a measles and polio vaccination drive to reach 920,000 children under age 5. Preceding the campaign, volunteers from the Togolese Red Cross Society conducted door-to-door and community social mobilization to inform people about the importance of protecting their children and the location of the vaccination and distribution centers.

As a result, coverage in Togo increased from 6 percent to 62 percent of households, and an estimated 98 percent of families with children under age 5 had at least one ITN. Under the innovative mechanism of delivering ITNs using the platform of measles immunization, the incremental delivery cost was less than 50 cents per ITN.18

Malawi and Tanzania have had success with social-marketing approaches for ITN distribution. In Malawi, ITNs were marketed through commercial outlets as well as in antenatal clinics and through community-based groups (at a highly subsidized price). In 2003 alone, 1 million ITNs were sold in Malawi, boosting coverage from 13 percent of the country’s households in 2000 to 43 percent by the end of 2004 to 60 percent in 2005 (see Table 2). The average cost per net delivered through this approach was US$2.63, with the cost per net decreasing with greater volume distributed.19

Table 2
Increases in ITN Converage in Malawi After Social Marketing Campaigns

Households with at least 1 net
Children under 5 protected by net
Pregnant women protected by net
Coverage (2000)
Nets sold (2000-2004)
1.6 million
Coverage (Feb 2004)
Nets sold (Mar-Dec 2004)
1 million
Estimated coverage
(Dec 2004)

Source: Population Services International, The Malawi ITN Delivery Model (2005).

But even with recent achievements in ITN distribution in more than 45 sub-Saharan African countries, only one country, Eritrea, has reached the Abuja target. Indeed, surveys from 1999 to 2004 in 34 African countries show that coverage of children under age 5 using ITNs was still only 3 percent.20

Moreover, in most African countries, many more households have mosquito nets that are not treated with insecticide, warranting a scaling up of ITNs to provide full coverage. Because the standard ITN needs to be re-treated every 6-12 months with insecticide, scaling up coverage should include parallel provision of re-treatment packets. Importantly, a new kind of net, which retains its insecticidal properties without needing frequent re-treatment, has been developed. These long-lasting insecticidal nets work for four to five years.21

Challenges and Policy Issues

Strong efforts are being made to boost ITN coverage, due in part to increased national and international funds. The creation of the Global Fund for AIDS, Tuberculosis and Malaria in 2001 provided another mechanism for increasing and leveraging resources for malaria prevention.22

About one-half of African countries have waived taxes and tariffs on nets, netting materials, and insecticides to expedite delivery of malaria prevention products.23 But many ITN delivery programs rely heavily on subsidized nets, especially for programs that aim for universal coverage through free distribution. Such reliance on donor support may undermine long-term sustainability. Despite the number of ITN delivery programs, evidence is still sparse regarding the best approaches to as well as the costs involved in scaling up programs.

If both universal coverage and sustainability are goals, a combination of “best buys”—ITNs, indoor spraying, and IPT—is optimal. But when the focus is children under age 5 and resources are limited, ITNs are the best strategy. Whereas various delivery methods have certain advantages depending on the target population, it is likely that coupling free distribution to target populations with marketing through commercial outlets can achieve the most ITN coverage.

Heidi Worley is a senior policy analyst at the Population Reference Bureau.


  1. World Health Organization (WHO), “Twentieth Report of the WHO Expert Committee on Malaria,” Technical Report Series 892 (Geneva: WHO, 2000).
  2. The Global Fund for AIDS, Tuberculosis, and Malaria (GFATM), “Malaria,” in HIV/AIDS, Tuberculosis, and Malaria: The Status and Impact of the Three Diseases (2005), accessed online at www.theglobalfund.org, on April 12, 2006.
  3. Joel G. Breman et al., “Conquering Malaria,” in Disease Control Priorities in Developing Countries, 2d ed., ed. Dean T. Jamison et al. (New York: Oxford University Press, 2006): 413-32.
  4. IPT in infancy (IPTi) involves giving infants treatment doses during vaccination or other well-baby visits to health clinics. Recently launched studies of intermittent preventive treatments during infancy are hoped to provide a more precise means of examining the benefits of IPTi and consequences on child development. See Penny A. Holding and Patricia K. Kitsao-Wekulo, “Describing the Burden of Malaria on Child Development: What Should We Be Measuring and How Should We Be Measuring It?” American Journal of Tropical Medicine and Hygiene 71, Suppl. 2 (2004): 71-99. Regarding programs that complement ITN, see Breman et al., “Conquering Malaria.”

  5. Roll Back Malaria (RBM), “Looking Forward: Roll Back Malaria,” accessed online at www.rollback malaria.org, on May 3, 2006.
  6. RBM/WHO, “The Abuja Declaration and the Plan of Action,” accessed online at www.who.int, on May 3, 2006.
  7. GFATM, HIV/AIDS, Tuberculosis, and Malaria: The Status and Impact of the Three Diseases.
  8. Endemic refers to situations in which there is a constant measurable incidence both of cases and of natural transmission in an area over a succession of years; WHO, World Malaria Report 2005 (Geneva: Roll Back Malaria Partnership, 2005) ; and GFATM, HIV/AIDS, Tuberculosis, and Malaria: The Status and Impact of the Three Diseases.
  9. WHO, World Malaria Report 2005.
  10. Eve Worrall, Aafje Rietveld, and Charles Delacollette, “The Burden of Malaria Epidemics and Cost-Effectiveness of Interventions in Epidemic Situations in Africa,” American Journal of Tropical Medicine and Hygiene 71, Suppl. 2 (2004): 136–140.
  11. RBM, “Looking Forward: Roll Back Malaria,” accessed online at www.rollback malaria.org, on May 3, 2006.
  12. United Nations, The Millennium Development Goals Report, accessed online at www.un.org/millenniumgoals, on May 3, 2006.
  13. DCPP is a collaborative effort of the Fogarty International Center of the U.S. National Institutes of Health, the World Bank, the World Health Organization, and the Population Reference Bureau and is supported by a grant from the Bill & Melinda Gates Foundation. For more information on the books or the project, visit the DCPP website at www.dcp2.org.
  14. Breman et al., “Conquering Malaria.”
  15. The insecticide has a wide coverage range; The Roll Back Malaria Partnership was launched in 1998 by WHO, the World Bank, UNICEF, and UNDP with the overall goal of halving the burden of malaria by 2010. The partnership includes malaria-endemic countries, their bilateral and multilateral development partners, the private sector, academia, and international organizations. See Roll Back Malaria Partnership, “RBM Partnership Consensus Statement on Insecticide Treated Netting: Personal Protection and Vector Control,” accessed online at www.rbm.who, on May 3, 2006.
  16. Jennifer Bryce et al., “Reducing Child Mortality: Can Public Health Deliver?” Lancet 362, no. 9378 (2003): 159-64.
  17. Bryce et al., “Reducing Child Mortality: Can Public Health Deliver?”
  18. WHO, World Malaria Report 2005.
  19. WHO, World Malaria Report 2005; Population Services International, “The Malawi ITN Delivery Model,” accessed online at www.psi.org, on May 5, 2006; Breman et al., “Conquering Malaria”; Warren Stevens et al., “The Costs and Effects of a Nationwide Insecticide-Treated Net Programme: The Case of Malawi,” Malaria Journal 4, no. 22 (2005): 1-6.
  20. WHO, World Malaria Report 2005.
  21. GFATM, HIV/AIDS, Tuberculosis, and Malaria: The Status and Impact of the Three Diseases.

  22. GFATM, How the Global Fund Works, accessed online at www.theglobalfund.org, on May 5, 2006.
  23. WHO, World Malaria Report 2005.