Although the finding of 80.5 % LLINs coverage rate in the households sampled meets the RBM target and is a significant improvement on the NDHS of 2008, it falls short of the country’s roadmap implementation target for 2010, which is a 95 % coverage rate [8
]. According to the 2008 NDHS report, 8 % of surveyed households owned at least one insecticide treated net (ITN), 3 % owned >1 ITN, and the average number of ITNs per household is
1. Ownership of ITNs was higher among households in the Southern zones and increased with wealth quintiles [8
]. In the NMCP, free LLINs are given only to pregnant women and children
5 years and the target of RBM is for 80 % coverage of LLINs by 2010. This improvement, however, can be attributed to the State-wide free LLINs distribution that took place about a year ago, since 81.1 % of those who owned LLINs had obtained them during the free distribution exercise. The shortfall could be accounted for by the abrupt halt in the free distribution exercise since majority of the respondents who did not have the nets were absent at the time of distribution. Lack of funding and the size of at risk population to be reached have been identified as major restricting factors to complete coverage of LLINs [12
Household ownership of LLINs was found to be equitably distributed across all quintiles as opposed to the 2008 NDHS which found that households in higher wealth quintiles significantly owned ITNs more than those in lower quintiles [8
]. The implication of this finding is that free LLINs distribution minimized inequalities in ownership of LLINs by enabling households in the poorest wealth quintiles to access this malaria control strategy. Other studies in African countries have revealed similar findings of decreased inequity following distribution of free ITNs [9
]. However, we find that there is significant equity difference in the ownership of more than 5 LLINs per household. Controversy still exists in this aspect as some studies have found that lower wealth quintiles owned more number of nets per household than higher ones, depending on the setting of the study, rural or urban [11
Over half of the households in this survey had members who slept under the LLINs the previous night. This is an improvement on the 2008 NDHS which found 49.8 % and 44.4 % utilization rates among children
5 years and pregnant women respectively, but it still falls short of the RBM target for 2010 which is an 80 % utilization rate [1
]. Among our respondents, the commonest reason for non-use of LLINs was that it made them sweat( 66 %), as opposed to a study in 2008, where 71.4 % of non-use was as a result of lack of awareness about LLINs and only 3.4 % for reason of sweating [23
]. This difference in reason for non-use could be explained by the increased utilization rates, since only those who use nets can experience sweating under them. Although a positive association can be drawn between LLIN ownership and use, we cannot from our study conclusively say that there is a causal relationship. Several studies in Africa have also found a positive relationship between LLINs ownership and use among households [19
Although ACTs were the most utilized for treatment of malaria, the utilization rates falls far short of the RBM target of 80 % by 2010 [24
]. There seems to be decrease in utilization of ACTs from our study when compared to a cross-sectional multi country survey on coverage rate of ACTs which found 52 % coverage rate among children in Nigeria in 2007 [25
]. This shortfall could be explained by the inconsistencies in the delivery of ACTs to the public health facilities which is being experienced in Anambra State. A quality assessment survey done by the Health Policy Research Group in November 2010 showed that 54.4 % of the primary health care facilities in Anambra State had been out of stock for ACTs for a period of at least 3 months [26
]. Studies in Africa have found that a large proportion of patients seek care at public health facilities first, and when they cannot access this care they resort to sub standard care for the reason of cost [27
]. This was consistent with our finding of the continued use of less efficacious antimalarials like chloroquine and Sulphadoxine-pyrimethamine which have high levels of drug resistance in Africa. Of greater concern is the use of artemisinin monotherapy (AM). Considering that the cost of one adult dose of the first choice ACT (Artemisinin-Lumefantrine) was calculated to be US$10.3 [28
], which is high especially where the mean total food expenditure as found in our survey is 6,785.23 (US$45.2), and the potential threats of drug resistance which AM poses to the only currently proven efficacious antimalarial (ACTs), there is need to scale-up free ACTs.
Despite the low utilization rate of ACTs, there was equity in access among the most vulnerable group, children less than five years old and pregnant women. Inconsistencies in delivery of free ACTs to public health facilities and cost of purchasing them when free ones are not available have been identified as the two major barriers to scaling up ACTs coverage rate among vulnerable groups. Subsidizing ACTs by 90 % was found to increase the proportion of consumers purchasing them for a significantly higher number of under-fives from 1 % to 44 % in one year in Tanzania [29
]. The fact that ACTs were provided free of charge in the public health facilities could explain the bridge in equity gap in access between the rich and the poor.
Free distribution of LLINs significantly increased its coverage rate and reduced inequities in ownership of nets across wealth quintiles. A positive association can be drawn between nets ownership and use. Distribution of free LLINs to all households is likely to achieve the goal of combating malaria regardless of socioeconomic status.
The free distribution exercise did not significantly improve ACT coverage among vulnerable groups, although inequities do not exist in the access to ACTs by the most vulnerable group, children less than five years. Sustainability and cost have been identified as major limiting factors to ACTs coverage.
Success of malaria control requires strong, sustained political and budgetary commitment. Policy makers and parliamentarians need to support the malaria control programs and health systems in their countries by providing and coordinating the necessary resources, especially financial; by helping to resolve bottlenecks in countries (e.g. taxes and tariffs, administrative or regulatory procedures); and coordinating all partners active in the country to reach rapidly the universal coverage targets.
Sustainability is the key to achieving lasting results. Behavior change communication approach will be an important tool to address the 10 % of respondents who still think use of LLINs is not an important malaria prevention strategy.
The main limitation of the study is that it is cross-sectional, not a randomized controlled trial. Therefore, strong cause and effect relationships cannot be established. The study was conducted less than one year after the roll out of free LLINs, so the increased coverage and use may be transient, and there is likelihood that it may drop with time as ITNs wear out. There may be a need for further studies with longer follow up periods to ascertain the sustainability of current coverage rates.
However, the strength of this study is that respondents (households) were selected randomly and therefore make a good representation of the study population. This implies that the results of the study will be reproduced if the whole population is used.
This study provides some information on how the national and international target of 80 % coverage and use of LLINs might be achieved, as well as reducing inequality through free distribution. Further research with an ideal randomized controlled design with sufficient households and time for follow up, should clarify the possible long-term impact of changing distribution policies from cost-sharing schemes to free distribution.