Summaryobjectives In December 2005 and March 2006, Niger conducted nationwide integrated campaigns to distribute polio vaccine and long lasting insecticide-treated nets (LLINs) to children <5 years of age. We evaluated the campaign effectiveness, net retention, insecticide-treated net (ITN) ownership, and usage.methods Two nationwide cross-sectional surveys in January 2006 (dry season) and September 2006 (rainy season), using a stratified two-stage cluster sampling design. We mapped selected communities, selected households by simple random sampling, and administered questionnaires by interviewers using personal digital assistants.results The first survey showed that ITN ownership in all households was 6.3% prior to the campaign, increasing to 65.1% after the campaign in the second survey. The second survey also showed that 73.4% of households with children <5 received an LLIN and that 97.7% of households that received ‡ one LLIN retained it. The wealth equity ratio for ITN ownership in households with children <5 increased from 0.17 prior to the campaign to 0.79 afterward. During the dry season, 15.4% of all children <5 and 11.3% of pregnant women slept under an ITN, while during rainy season, 55.5% of children <5 and 48.2% of pregnant women slept under an ITN.conclusions Free distribution during the integrated campaign rapidly increased ITN ownership and decreased inequities between those in the highest and lowest wealth quintiles. Retention of ITNs was very high, and usage was high during malaria transmission season. However, ITN ownership and usage by vulnerable groups continues to fall short of RBM targets, and additional strategies are needed to increase ownership and usage.

Action is urgently needed. Our results suggest that to improve health care delivery, interventions should target both the health system and the community level.

IMCI training was useful but insufficient. Relatively inexpensive supports can lead to additional improvements.

Summaryobjective To describe an approach for evaluating the impact of malaria control efforts on malariaassociated mortality in sub-Saharan Africa, where disease-specific mortality trends usually cannot be measured directly and most malaria deaths occur among young children.methods Methods for evaluating changes in malaria-associated mortality are examined; advantages and disadvantages are presented.results All methods require a plausibility argument-i.e., an assumption that mortality reductions can be attributed to programmatic efforts if improvements are found in steps of the causal pathway between intervention scale-up and mortality trends. As different methods provide complementary information, they can be used together. We recommend following trends in the coverage of malaria control interventions, other factors influencing childhood mortality, malaria-associated morbidity (especially anaemia), and all-cause childhood mortality. This approach reflects decreases in malaria's direct and indirect mortality burden and can be examined in nearly all countries. Adding other information can strengthen the plausibility argument: trends in indicators of malaria transmission, information from demographic surveillance systems and sentinel sites where malaria diagnostics are systematically used, and verbal autopsies linked to representative household surveys. Health facility data on malaria deaths have well-recognized limitations; however, in specific circumstances, they could produce reliable trends. Model-based predictions can help describe changes in malaria-specific burden and assist with program management and advocacy.conclusions Despite challenges, efforts to reduce malaria-associated mortality in Africa can be evaluated with trends in malaria intervention coverage and all-cause childhood mortality. Where there are resources and interest, complementary data on malaria morbidity and malaria-specific mortality could be added.