Presented at the 2015 American Society of Tropical Medicine and Hygiene (ASTMH) Annual Meeting.

1. Background
Worsening Socio-economic Disparities in ITN Ownership, Access and Use
from 2006 to 2011 in Angola
Methods
Insecticide-treated nets (ITNs) are a key malaria control intervention as they significantly decrease malaria morbidity and
mortality. However, in many malaria endemic countries, ITN coverage remains low and is inequitable among different socio-
economic groups. In Angola, despite an increase in ITN use among children under five (18% 2006/7 to 26% in 2011) for example,
it still remains far below the target of 85%. Using data from the two Malaria Indicator Surveys (MIS), this study investigated
change in equity in ITN ownership, access, and use among children under five between 2006/7 and 2011 in Angola.
Results
• 2006/7 and 2011 Angola Malaria Indicator Surveys (MIS)
•MIS 2006/7 (Fieldwork: November 2006–April 2007)
•MIS 2011 (Fieldwork: February–May 2011)
• Proportion of households with at least one ITN
• Proportion of population with access to an ITN within their household
• Proportion of children under 5 years old who slept under an ITN the
previous night
• Lorenz Concentration Curves and the Lorenz Concentration Index (C-Index) were used to
assess equity in household ITN ownership, access and use among children under five across
household wealth quintiles.
• While the C-Curve graphically presents the gap in relation to an equity line, the C-Index,
which is directly related to the Lorenz Concentration Curve, quantifies the degree of socio-
economic related inequality in a health variable. C-Index values range between -1 to 1. A
value of 0 suggests no difference in ownership and use among different socioeconomic
groups. C-Index is greater than 0 (<0) if the outcome is disproportionately concentrated on
population from the highest (lowest) wealth quintile.
Conclusion
Disparities in ITN ownership, access and use worsened between socio-economic groups. ITN ownership was less equitable in 2011
(C-index: 0.17) compared to 2006/7 (C-index: 0.05). In 2011, 44% of households from the least poor wealth quintile owned at least
one ITN compared to 15% in the poorest quintile. This disparity was less in 2006/7; 31% compared to 26% respectively. Similar
results were found for ITN access (C-index: 0.16 and 0.02) and use among children under five (C-index: 0.17 and -0.004)). Despite an
increase in ITN ownership, access and use between 2006/7 and 2011 in Angola, inequity became greater, favoring the least poor
quintiles. This could be due to different ITN distribution strategies implemented. Before the MIS 2006/7, there was a massive free
net distribution campaign implemented in seven provinces. Afterwards, ITNs were mainly distributed through routine antenatal
care. Universal coverage distribution began in 2010, but was limited to specific municipalities. ITNs therefore became more
accessible to those living closer to facilities (most in urban areas) and who could afford them. A different strategy for ITN
distribution that results in both higher and more equitable coverage is needed in Angola.
Acknowledgments
This study was made possible by support
from the U.S. Agency for International
Development (USAID) under the terms of
Cooperative Agreement GPO-A-00-03-00003-
00. The opinions expressed are those of the
authors and do not necessarily reflect the
views of USAID, or the United States
Government.
Data Sources
Analysis
Ana Claudia Franca- Koh1, Lia Florey2, Samantha Herrera1, Jui Shah1, Cameron Taylor2 , Rebecca Winter2, Yazoume Ye1
1MEASURE Evaluation, ICF International 2The DHS Program, ICF International
Figure 3: Equity of household ownership of ITNs
© Sian Curry
Indicators
Source: Malaria Indicator Surveys
Figure 4: Equity of children under five using ITNs
Figure 1: Household Ownership of ITNs (%)
Figure 2: ITN Use Among Children Under 5 (%)
1028
28
35
2006/7 2011
% household own ≥ 1 ITN
18
26
2006/7 2011
% under-fives used ITN last night
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80 90 100
Cumulativepercentageofwealthquintiles
amonghouseholdsowningatleast1ITN
Cumulative percentage of wealth quintiles in sample
Equity line 2006/7 2011
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80 90 100
Cumulativepercentageofwealthquintiles
amongchildrenunder-fiveusingITN
Cumulative percentage of wealth quintiles in sample
Equity Line 2006/7 2011