Inequalities in Household Access to Insecticide-Treated Nets and Indoor Residual Spraying in 34 African Countries

BackgroundMalaria control through insecticide-treated nets (ITNs) and indoor residual spraying (IRS) is essential in sub-Saharan Africa. This study assesses wealth status and residence-based inequalities in household access to these interventions across 34 African countries. MethodsA cross-sectional analytical design was used, drawing on nationally representative household surveys (Demographic and Health Surveys, Malaria Indicator Surveys, multiple Indicator Cluster Surveys) collected between 2005 and 2018. Data from the WHO Health Equity Monitor provided equity-disaggregated indicators on ITN/IRS coverage by wealth quintile and place of residence (rural/urban). The primary outcome was the percentage of households with at least one ITN and/or IRS coverage in the previous 12 months. We calculated both the percentage and disparities of inequalities across four inequality dimensions: difference (D), ratio (R), population-attributable risk (PAR), and population-attributable fraction (PAF) ResultsThe ITN and/or IRS coverage varied widely from countries, highest in Mali (93.6%), Benin (92.0%), Burkina Faso (89.8%), and Rwanda (89.2%), and lowest in Ethiopia (3.4%) and Eswatini (4.4%). Wealth-related inequalities included pro-rich patterns with Burundi reporting the largest absolute difference (D = 33.6 percentage points), ratio (R = 2.1), population attributable risk (PAR = 17.5), and population attributable fraction (PAF = 37.5%). Other countries with notable pro-rich disparities included Sao Tome and Principe (D = 28.8; R = 1.7; PAR = 12.1; PAF = 20.0%) and Malawi (D = 24.2; R = 1.5; PAR = 12.2; PAF = 20.8%). The strong pro-poor patterns were observed in Namibia (D = -36.5; R = 0.3), Gambia (D = -28.6; R = 0.7), and Nigeria (D = -28.2; R = 0.7), with marginal PAF, indicating minimal inequality-related coverage loss. Rural-urban disparities also varied, with Burundi showing a pro-urban absolute difference (D = 20.3), ratio (R = 1.5), PAR (18.1), and PAF (38.7%), whereas Zimbabwe (D = -31.5; R = 0.5) and Namibia (D = -32.7; R = 0.3) exhibited pro-rural advantages. ConclusionsThe study shows persistent wealth-related and geographical inequalities in access to ITNs and IRS across sub-Saharan Africa. Targeted efforts aimed at reducing these disparities are essential to achieving equitable and universal malaria prevention coverage consistent with global malaria and Sustainable Development Goal targets.