Efficiencies in the allocation of insecticide-treated nets for malaria prevention in urban Sub-Saharan Africa

The extent to which insecticide-treated nets (ITNs), a key malaria prevention intervention in Sub-Saharan Africa, have been appropriately targeted to those at highest risk remains unknown, particularly within the urban context. We combined household surveys, programmatic ITN distribution data, and procurement cost data to estimate the number and cost of ITNs distributed in urban areas of Sub-Saharan Africa over the period 2010-2021, as well as trends in malaria prevalence and ITN access by wealth quintile. We estimate that over 440 million ITNs at a cost of over $1B USD have been distributed in urban areas, and allocations between rural and urban areas did not proportionately reflect the higher risk of malaria in rural areas. In urban areas, households in lower wealth quintiles were at higher risk of malaria but did not have greater access to ITNs. Housing quality and wealth but not ITN access or use were associated with decreased malaria prevalence in urban areas. If ITNs in urban areas had been distributed solely to slum residents, over $200 million could have been freed for other malaria control activities. In the context of needing to prioritize increasingly limited resources for health, ITN distributions must be better targeted to the most vulnerable.