International Recommendations on Universal Coverage

To reduce malaria transmission, World Health Organization (WHO) recommends that countries aim for universal coverage with ITNs. WHO recommends that both large-scale mass distribution campaigns and CD both occur as part of a multi-channel strategy to achieve and maintain universal access to ITNs. CD occurs within the routine health care system, such as ANC clinics and those that provide services under the EPI; and through other distribution points, such as schools, community outlets, and programs involving the private sector.

To achieve Universal Coverage, the entire population at risk must have access to an ITN every night. Factors such as prioritization and sleeping patterns within households, will affect access, making true access extremely difficult to measure. The international consensus, however, is that universal access would be achieved if every household had at least one ITN for every two people[1]. The assumption is that this will amount to Universal Access, as most ITNs will be shared by two people on average. Data from a range of countries show that this is usually the case.

The term ‘Universal’ suggests a target of 100% of people sleeping under an ITN every night—the ideal goal. Most countries have set more realistic targets, a little lower than this, most commonly at 80% or 85% of the population having access to an ITN within the household. Ideally, this level should be set no lower than the minimum coverage needed to have an impact on malaria transmission. Realistically, it is impossible to specify what this coverage level is, because it will be different in different settings. It is assumed for the purposes of this toolkit that 80% to 85% of people with access to an ITN, plus a high access-to-use ratio of over 80%, will be sufficient to achieve the objectives of Universal Coverage.

The Importance of a Mix of Delivery Channels

Large-scale ITN distribution campaigns can achieve rapid, high coverage with ITNs, but maintaining this coverage appears to require a more complex mix of delivery options. ITN coverage begins to decline rapidly after campaigns as a result of ITN damage, loss, or population growth. More frequent deliveries, either continuously or at regular intervals, are critical for keeping coverage sufficiently high between campaigns. Having a mix of different delivery activities is important for two main reasons:

To make enough ITNs available for families that need new or replacement ITNs to keep family members covered. One channel may not distribute sufficiently high numbers of ITNs into families.
To make ITNs as equitably available as possible. Certain population subgroups—be they socioeconomic strata or geographically defined groups—may not access some potential ITN distribution channels. To maintain the equitable coverage that mass campaigns achieve, a mix of approaches to continuous delivery will need to consider equity of access.

The most appropriate mix of channels for any setting will depend on four main considerations:

  • Quantities: the mix of channels should be expected to lead to ITN turnover that is sufficient to meet replacement ITNs needs but without over-supplying.
  • Equity of access: the combination of channels should provide good access across the population.
  • Practicality: the mix of channels must not create too many logistical challenges; these will affect affordability and whether predicted distribution quantities are achieved.
  • Affordability: some desirable channels may not be affordable in some settings.

Designing an overarching strategy for Universal Coverage

Comprehensive national strategies for ITNs (now, more commonly, ITN strategies) should include components both to achieve, and then to maintain, access targets. This overall strategy will need to include both large-scale mass distribution campaigns and continuous distribution (CD) approaches. A strategy for continuous ITN distributions should always be part of a wider national ITN strategy; which, in turn, will be part of the overall malaria control strategy. The national goal, vision, and mission statement will inform the wider ITN strategy; a separate goal and vision for the CD component is not appropriate. Box 1 reviews the importance of the overall strategy, including both campaign and CD approaches.

The overall ITN strategy must be designed to achieve and maintain high and equitable ownership and access.

Sustaining Universal Coverage

Achieving high ownership and access levels

So far, large-scale mass campaigns are the only delivery mechanism, conceived and put into practice that has achieved rapid, sizable, and equitable increases in ITN ownership and access. Recent, particularly good successes include campaigns in Senegal, Mali, Tanzania and Uganda. However, ownership and access levels will start to fall almost immediately with the ‘loss’ of ITNs through various causes—starting gradually and increasing over the next few years. Other distributions will, therefore, need to top up to target levels and then maintain these levels during the medium to long term. Many resources are available for countries planning and managing mass ITN campaign distributions. The Alliance for Malaria Prevention toolkit is a good starting point.

Maintaining high ownership and access levels

Numerous possible mechanisms are available to maintain access levels.

Repeated—every three years or so—mass campaigns currently have an important role in maintaining coverage. However, rather than adopting a strategy that relies only on numerous repeat campaigns, with the expected drop in coverage between campaigns, countries could consider a more diverse approach by combining a number of CD mechanisms to ensure that ITN access and ownership remains at or above target levels at all times.

Maintaining equitable ownership and access

A major advantage of mass campaign distributions is their equity; free mass campaign distribution is the only distribution mechanism repeatedly shown to reach all socio-economic groups equally. In contrast, the most commonly used continuous mechanisms have rarely achieved equity equal to that of mass campaign distributions, even when the ITNs are provided free. The equity of uptake of ITNs through these continuous mechanisms is linked to the equity of access to the chosen delivery channel. In the case of the most common channels—health facilities, commercial outlets, and schools—access is known to be, to varying degrees, more inequitable for the poorer quintiles than mass campaigns.

This means that high and equitable ownership of and access to ITNs can be achieved through campaigns, but, as ownership begins to fall in the years following the campaign, replacement ITNs are provided through the less equitable CD channels. As a result, ownership of and access to ITNs in the population may gradually become less equitable. A strategy mix that can maintain equitable ownership and access will need to include specific distribution strategies aimed at the groups missed by the main CD channels.

More information on considering equity in CD is included throughout this website.

[1] Roll Back Malaria (RBM)/ RBM Partnership Monitoring and Evaluation Group (MERG), Survey Indicator Guidance Task Force. Meeting report, 5–6 April 2011, New York, USA.