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, 14 (2), e0212890

The Impact of an Insecticide Treated Bednet Campaign on All-Cause Child Mortality: A Geospatial Impact Evaluation From the Democratic Republic of Congo


The Impact of an Insecticide Treated Bednet Campaign on All-Cause Child Mortality: A Geospatial Impact Evaluation From the Democratic Republic of Congo

Carrie B Dolan et al. PLoS One.


Objective: To test the impact of a nationwide Long-Lasting Insecticidal Nets [LLINs] distribution program in the Democratic Republic of Congo [DRC] on all-cause under-five child mortality exploiting subnational variation in malaria endemicity and the timing in the scale-up of the program across provinces.

Design: Geospatial Impact Evaluation using a difference-in-differences approach.

Setting: Democratic Republic of the Congo.

Participants: 52,656 children sampled in the 2007 and 2013/2014 DRC Demographic and Health Surveys.

Interventions: The analysis provides plausibly causal estimates of both average treatment effects of the LLIN distribution campaign and geospatial heterogeneity in these effects based on malaria endemicity. It compares the under-five, all-cause mortality for children pre- and post-LLIN campaign relative to children in those areas that had not yet been exposed to the campaign using a difference-in-differences model and controlling for year- and province-fixed effects, and province-level trends in mortality.

Results: We find that the campaign led to a 41% decline [3.7 percentage points, 95% CI 1.3 to 6.0] in under-5 mortality risk among children living in rural areas with malaria ecology above the sample median. Results were robust to controlling for household assets and the presence of other health aid programs. No effect was detected in children living in areas with malaria ecology below the median.

Conclusion: The findings of this paper make important contributions to the evidence base for the effectiveness of large scale-national LLIN campaigns against malaria. We found that the program was effective in areas of the DRC with the highest underlying risk of malaria. Targeting bednets to areas with greatest underlying risk for malaria may help to increase the efficiency of increasingly limited malaria resources but should be balanced against other malaria control concerns.

Conflict of interest statement

CD and ABY work for AidData at the College of William and Mary, which received a small research grant from the World Bank Group’s Independent Evaluation Group to support this evaluation. KG, GM, DCW, and ADK have no conflicts of interest to declare. JT is an employee of the World Bank Group, which was involved in the implementation of some of the malaria control activities in the DRC, however, he works in the Independent Evaluation Group and we do not believe his employee affiliation affected his work on this project. This does not alter our adherence to PLOS ONE policies on sharing data and materials.


Fig 1
Fig 1. Dates of long-lasting insecticide treated net mass campaigns.
Fig 2
Fig 2. Average Malaria Ecology Index and Demographic Health Survey sampling locations.
Fig 3
Fig 3. Average mortality risk over the range of average MEI.
Fig 4
Fig 4. Treatment effect by quintile.
Fig 5
Fig 5. Results of distributed lag-lead model.

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Grant support

This work was partially funded through a generous grant from the government of Japan through a Policy and Human Resources Development Grant, for which the team is grateful. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.