Evaluation of nation-wide insecticide-treated bednet distribution in Togo

The Togo National Integrated Child Health Campaign of December 2004 targeted all Togolese children ages 9-59 months for measles immunization and ITN distribution. Three years after this campaign, a population-based survey of approximately 12,000 households conducted to evaluate the malaria prevention intervention found that approximately 40% of households had received at least one ITN during the campaign. The first objective of this study was to evaluate the equity of this campaign by examining the determinants of the receipt of ITNs. We further examined the mortality impact of these ITNs among young children. For this second objective, we used a simultaneous equation approach in order to address the issue of endogeneity, that is, mothers who received ITNs during the campaign tend to employ other health-enhancing practices for their children than mothers who did not receive ITNs; therefore, the hypothesized protective effects of ITNs against mortality may be confounded with the protective effects of these unmeasured practices, thus overestimated. We also assessed the community-effects of ITN distribution, since ITN coverage at the community level may reduce mortality among children who are not directly protected by ITNs in their households. The results suggested that ITN distribution accomplished a high level of equity, reaching poor communities across Togo, although not reaching the poorest women within communities. It was also demonstrated that nation-wide ITN distribution significantly reduced child mortality, proving its effectiveness at preventing malaria. However, whether high ITN coverage at the community level had an additional, protective effect against mortality was not conclusive.