Which delivery systems reach the poor? A review of equity of coverage of ever-treated nets, never-treated nets, and immunisation to reduce child mortality in Africa.

Insecticide-treated nets (ITNs) and childhood vaccination are two of the most powerful interventions available to prevent childhood mortality in Africa, but ITN coverage is still very low. Current debates about how to increase ITN coverage are concerned with the roles of different supply and delivery systems, in particular whether or not commercial net markets have any useful role. Here, we review data available on coverage and equity of coverage of three interventions to prevent childhood mortality. We compiled and analysed data from nationally representative surveys in 26 African countries to compare equity of coverage of (1) the Expanded Programme on Immunisation (EPI), (2) any net, (3) ever-treated nets (ie, ITNs), and (4) never-treated nets (ie, untreated nets; UTNs). We assumed that ever-treated net coverage mostly reflects the activities of public-health programmes and projects, and that never-treated net coverage mostly reflects the activity of local unsubsidised commercial markets. We discuss the validity, limitations, and possible biases of these assumptions. We estimate that 87% of the 8.4 million children protected by nets used UTNs. We used the concentration index (CI) to assess equity of coverage of the interventions. The data shows that never-treated net coverage is surprisingly equitable: overall, and despite substantial regional variations, it is comparable in equity to EPI (median CI(UTN)=0.166, CI(EPI)=0.075; p=0.3). In almost all countries, coverage of ITNs is strongly concentrated in the least poor households, and significantly more inequitable than both UTNs (median CI(ITN)=0.435, mean CI(UTN)=0.158; p<0.001) and EPI (median CI(ITN)=0.435, CI(EPI)=0.075; p<0.001). These results suggest that the public-health value of commercial net markets has been greatly underestimated, and that these markets have so far contributed more to equitable and sustainable coverage of mosquito nets, and hence to the prevention of malaria in Africa, than have the ITNs delivered by public-health systems and projects.