In the 1990s and through the early 2000s, malaria mortality rates and malaria incidence rose to their highest recorded levels, experienced most acutely in Africa. Yet during this period, global malaria funding and global public health spending more generally were at historically low levels. Additionally, the toolkit for preventing, diagnosing, and treating malaria during this period was limited compared with the suite of tools that have since become more widely available. Insecticide-treated bednets (ITNs) represented a hopeful shift in the global fight against malaria in this context devoid of rapid diagnostics and widespread access to effective antimalarials or broader improvements in public health measures to control malaria’s spread. Field-tested throughout the 1980s and 1990s and scaled globally in the 2000s and into the 2010s, ITNs became a cornerstone of most malaria-control programs by the late 2000s.

This case study analyzes the causal factors in the global scaleup of ITNs, particularly from 2000 through 2010, with an emphasis on the roles of research and philanthropic funding. In particular, this case study seeks to identify the specific causal mechanisms that enabled the exponential growth in global ITN distribution and in global malaria funding.

Between 2004 and 2009, global ITN distribution increased nearly twentyfold, from 5.6 to 101.7 million nets, and in 2014 it rose to 200 million. Together with other advances in malaria-control and vector-control interventions, ITNs contributed to a 40 percent reduction in global malaria mortality rates between 2000 and 2015 and prevented as many as hundreds of millions of malaria cases. Given this success in reversing mortality and morbidity trends, ITNs are often celebrated as one of the greatest achievements in global health in recent memory, and frequently appear in the global health and health economics literature as a “best buy” for public health.

Despite this success, however, the path to global ITN scaleup was not straightforward, nor was it guaranteed. Instead, each step on this path was contingent upon each preceding step. Robust evidence existed by 2000 demonstrating the effectiveness and cost-effectiveness of ITNs in preventing child mortality, yet inertia following several decades of inaction on malaria carried well into the aughts. The global scaleup of ITNs during the 2000s was the product of multiple intersecting causal factors, any of which, if absent, might have prevented further progress. The growth in global ITN distribution in the 2000s required sustained collective action and coordination at the global, national, and local levels from all involved: researchers, implementers, net manufacturers, policymakers, donors, and net users.

This case study identifies 7 key factors that constrained ITN scaleup efforts and 10 key factors that enabled scaleup. Constraining factors were

1. severely insufficient global malaria funding before 2005;
2. lack of political will at international institutions to control malaria in Africa before the early aughts; 
3. insufficient manufacturing capacity to meet global demand for ITNs; 
4. lack of consensus around the optimal ITN delivery model, shaped in part by ideological and theoretical opposition to free health products; 
5. operational and logistical challenges; 
6. lack of coordination across implementing organizations; and 
7. lack of clear policy and technical guidance for implementation. 

Enabling factors were 

1. purchasing power created primarily by the Global Fund to Fight AIDS, Tuberculosis and Malaria and secondarily by the President’s Malaria Initiative; 
2. robust evidence of ITN effectiveness, cost-effectiveness, and implementation feasibility generated through randomized controlled trials, effectiveness trials, and large-scale integrated child survival campaigns;
3. multisectoral partnerships and collective action; 
4. political will from multilateral agency heads and heads of state championing malaria control; 
5. political will from the broader public; 
6. consensus around mass free distribution as the optimal delivery model (dependent in part upon all five preceding factors);
7. attributes of ITNs and product innovation (i.e., the development of long-lasting ITNs); 
8. increased global ITN production capacity; 
9. technical guidance and support; and 
10. clear policy guidance.