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Equity in Long-Lasting Insecticidal Nets and Indoor Residual Spraying For Hailu et al. Malar J (2016) 15:366 DOI 10.1186/s12936-016-1425-0 Malaria Journal RESEARCH Open Access Equity in long‑lasting insecticidal nets and indoor residual spraying for malaria prevention in a rural South Central Ethiopia Alemayehu Hailu1,2*, Bernt Lindtjørn1, Wakgari Deressa3, Taye Gari4, Eskindir Loha4 and Bjarne Robberstad1,5 Abstract Background: While recognizing the recent achievement in the global fight against malaria, the disease remains a challenge to health systems in low-income countries. Beyond widespread consensuses about prioritizing malaria pre- vention, little is known about the prevailing status of long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) across different levels of wealth strata. The aim of this study was to evaluate the socioeconomic related dimen- sion of inequalities in malaria prevention interventions. Methods: This study was conducted in July–August 2014 in Adami Tullu district in the South-central Ethiopia, among 6069 households. A cross-sectional data were collected on household characteristics, LLIN ownership and IRS cover- age. Principal component analysis technique was used for ranking households based on socioeconomic position. The inequality was measured using concentration indices and concentration curve. Decomposition method was employed in order to quantify the percentage contribution of each socioeconomic related variable on the overall inequality. Results: The proportion of households with at least one LLIN was 11.6 % and IRS coverage was 72.5 %. The Erreygers normalized concentration index was 0.0627 for LLIN and 0.0383 for IRS. Inequality in LLIN ownership was mainly asso- ciated with difference in housing situation, household size and access to mass-media and telecommunication service. Conclusion: Coverage of LLIN was low and significant more likely to be owned by the rich households, whereas houses were sprayed equitably. The current mass free distribution of LLINs should be followed by periodic refill based on continuous monitoring data. Keywords: Ethiopia, Equity, Malaria prevention, LLIN, IRS, Inequality analysis, Concentration index Background widespread around the globe, putting approximately 3.3 In the last decade, the global fight against malaria billion people at risk [1]. reaches on promising phase. Between 2000 and 2013, Malaria is one of the leading health problems in Ethio- malaria mortality was reduced by 47 % worldwide and pia. Records from the Ministry of Health (MoH) reveal by 54 % in Africa. During the same period, deaths from that more than 75 % of the total land mass is endemic malaria dropped by half in Ethiopia. However, malaria and about 68 % of the population is living in a malari- still remains to be one of the major challenges for the ous area [2]. The World Health Organization (WHO) health system in low-income countries. The disease is report more than 3.7 million cases of malaria infection for the year 2012 [3], and more than 2.1 million of cases for 2013 [4], in Ethiopia. Malaria is also one of the lead- *Correspondence: [email protected] ing causes of outpatient visits, inpatient admissions and 2 Department of Reproductive Health and Health Service Management, hospital deaths. In the malaria endemic districts of Oro- School of Public Health, Addis Ababa University, P.O. Box 9086, Addis mia region, malaria account for up to 29 % of all outpa- Ababa, Ethiopia Full list of author information is available at the end of the article tient visits [5], while in Adami Tullu district, where this © 2016 The Author(s). This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Hailu et al. Malar J (2016) 15:366 Page 2 of 11 paper emanates, malaria parasitic prevalence peaks up to Worrall et al. [19], based on review of several literatures, 10.4 % [6]. A recent study by Gari et al. similarly reported and Filmer [20], using 29 Demographic and Heath Sur- a higher incidence of malaria cases (4.6 cases per 10,000 veys (DHS) data from 22 countries, establish a very weak person-weeks of observation) from the same area [7]. link between malaria incidence and wealth status at The incidence peaks biannually from September to micro-level. No differences were found at the household December and April to May, both coinciding with har- level in the incidence of fever between the poor and less vesting seasons [8]. This has a serious consequence for poor [20]. Similarly, a recent study by Gari et al. from the Ethiopian farmers whom constitute the vast majority of same area also found no significant association between the total population. The consequences regard both the wealth status and incidence of malaria [7]. farmers, who are dependent on subsistence agriculture The underlying assumption is that at individual or for livelihood, but also more broadly the economic devel- household level, the odds of malarial infection is quite opment of the country. Studies consistently show also similar if either of them are not using the preventive malaria imposes heavy sanctions on economic growth measures. Therefore the argument that the socioeco- and causes household impoverishment [9, 10]. nomically better-off are in a better position to access the Malaria causes multifaceted problems which demand other non-publicly financed means of malaria preven- priority as well as synergistic intervention. Prevention of tion including mosquito repellent or window meshes malaria using long-lasting insecticidal nets (LLINs) and could not be justified given that the availability in rural indoor residual spraying (IRS) has been demonstrated setting is limited. For this reason, this paper emphasizes to be cost-effective interventions in different contexts. that malaria prevention interventions (LLINs and IRS) A systematic review indicates a median incremental should be owned equitably at any given time. However, cost effectiveness ratio (ICER) per disability adjusted the Ethiopian government has committed to follow pro- life year (DALY) averted of $27 for insecticide-treated poor universal health service delivery strategy, which nets (ITNs), and $143 for IRS [11]. These tools have been goes beyond policy statements of creating equal access to scaled up in the last decade aiming towards a universal health services for all groups of population [21]. access and to interrupt malaria transmission in malaria- In a nutshell, in this malaria elimination and eradica- endemic developing countries [12]. tion era, information on the equity dimension is more The results of the last two malaria indicator surveys important than ever for priority setting and resource (MIS) showed a remarkable stride in malaria prevention allocation [22–24]. In contrast, little is currently known and control services in Ethiopia. For example: ITN own- about who benefits from prevention efforts. Where ership in malaria endemic areas improved from 3.4 % in are those freely distributed bed nets? Who owns them? 2005 [13] to 65.6 % in 2007 [14]. Overall, 68 % of house- Whose houses are sprayed or not? These questions reflect holds in malaria endemic areas were protected by at least concerns about social justice and fairness, and have so one LLIN or indoor residual spraying of households with far not systematically been investigated. In this paper, insecticide [15]. Thirty percent of IRS targeted areas were household survey data were used to evaluate the socio- sprayed in 2007 and in 2008 the coverage increased to economic related dimension of inequalities in malaria 50 % [16]. So far, (since 2005 till 2014), a total of 64.2 mil- prevention interventions (LLIN and IRS) in a district in lion ITNs have been distributed [17]. Currently, Ethiopia south-central Ethiopia. Therefore, the hypothesis is that aims to achieve universal coverage by distributing one the poor families are equally likely to own the LLINs LLIN per 1.8 persons through mass and free distribution and to live in a house treated with IRS compared with campaigns at the community level through the health better-offs. extension workers and health facilities. Usually, LLINs are distributed by periodic mass campaigns that occur Methods about every 3 years in a rotation basis [2]. Study area and participants Beyond mere emphasis on overall coverage, malaria This study is part of a large cluster randomized con- prevention services in general and LLIN ownership trolled trial, which aim to evaluate the combined use of and IRS status in particular, should be fair regardless of LLINs and IRS against each intervention alone in pre- socioeconomic status over time. Both LLIN and IRS are venting malarial infection [25]. This study uses data from mainly financed through the MoH either from donation a baseline household survey conducted in July–August or direct government budgeting. Therefore, unargu- 2014 in Adami Tullu district of Oromia region in south- ably, the benefits from these publicly financed interven- central Ethiopia. The survey was conducted in 13 vil- tions shall be distributed equitably. A test regarding this lages, located within 5 km from the shore of Lake Ziway. normative position is that the odds of malaria infection Overall, 31,284 individuals from 6069 households were should be the same for all socioeconomic classes [18]. included. Hailu et al. Malar J (2016) 15:366 Page 3 of 11 The district is situated in the heart of the Great Rift was measured by direct observation by the data collec- Valley. Most of the villages are located in the lowland tors while IRS status was assessed based on what the portion, while the elevation ranges from low altitude of household head reported.
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