Mobilizing stakeholders for implant removals in Burkina Faso using landscape assessment data.

BACKGROUND: Successful efforts to encourage uptake of subdermal contraceptive implants, with a lifespan of three to five years, necessitate planning to ensure that quality removal services are available when desired. In Burkina Faso, implant use has tripled over the past 8 years and now comprises almost half of the contraceptive method mix. Population Monitoring for Action (PMA) surveys identified barriers to obtaining quality removal when desired, particularly when the implant is not palpable, or providers lack needed skills or supplies. The Expanding Family Planning Choices (EFPC) project supported ministries of health in four countries with evaluation and strengthening of implant removal services. METHODS: An implant removal landscape assessment was conducted at 24 health facilities in three regions of Burkina Faso with high implant use that included provider observations of implant removal, interviews with providers and health facility managers, and facility readiness surveys. The project used landscape data to mobilize stakeholders through a series of participatory workshops to develop a collaborative roadmap and commit to actions supporting quality implant removals. RESULTS: Landscape findings revealed key gaps in provision of quality removal services, including high levels of provider confidence for implant insertion and removal (82% and 71%, respectively), low competence performing simple and difficult removals (19.2% and 11.1%, respectively), inadequate supplies and equipment (no facilities had all necessary materials for removal), lack of difficult removal management systems, and a lack of standard data collection tools for removal. Exposure to the data convinced stakeholders to focus on removals rather than expanding insertion services. While not all roadmap commitments were achieved, the process led to critical investments in quality implant removals. CONCLUSION: Landscape data revealed that facilities lack needed supplies and equipment, and providers lack skills needed to perform quality implant removals, limiting client reproductive choice. Disseminating this data enabled stakeholders to identify and commit to evidence-based priority actions. Stakeholders have since capitalized on program learnings and the roadmap, including following MOH guidance for implant removal supplies and health provider training. Our experience in Burkina Faso offers a replicable model of how data can direct collective action to improve quality of contraceptive implant removals.

Community-based delivery of intermittent preventive treatment of malaria in pregnancy in Burkina Faso: a qualitative study.

BACKGROUND: Burkina Faso is among ten countries with the highest rates of malaria cases and deaths in the world. Delivery and coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) is insufficient in Burkina Faso; In a 2016 survey, only 22% of eligible women had received their third dose of IPTp. It is also an extremely rural country and one with an established cadre of community healthcare workers (CHWs). To better meet the needs of pregnant women, an enhanced programme was established to facilitate distribution of IPTp at the community level by CHWs. METHODS: In order to assess the perceptions of CHWs and facility healthcare workers (HCWs) involved in this programme rollout, semi-structured interviews were conducted at three high malaria burden health districts in Burkina Faso. Interviews were conducted at baseline with 104 CHWs and 35 HCWs prior to the introduction of community based IPTp (c-IPTp) to assess capacity and any areas of concern. At endline, interviews were conducted with 29 CHWs and 21 HCWs to identify key facilitators and suggestions for further implementation of the c-IPTp programme. RESULTS: CHWs reported feeling capable of supporting c-IPTp delivery and facilitating linkage to antenatal care (ANC). They noted that the opportunity for enhanced training and close and ongoing connections with facility HCWs and supportive supervision were imperative. Both CHWs and HCWs perceived this approach as acceptable to community members and noted the importance of close community engagement, monthly meetings between CHWs and facility HCWs, and maintaining regular supplies of sulfadoxine-pyrimethamine (SP). Those interviewed noted that it was beneficial to have the involvement of both female and male CHWs. CONCLUSIONS: Community-based delivery of IPTp was feasible and acceptable to both facility HCWs and CHWs. This approach has the potential to strengthen delivery and uptake of IPTp and ANC both in Burkina Faso and across the region.

A cluster randomized trial of delivery of intermittent preventive treatment of malaria in pregnancy at the community level in Burkina Faso.

BACKGROUND: Malaria in pregnancy is responsible for 8-14% of low birth weight and 20% of stillbirths in sub-Saharan Africa. To prevent these adverse consequences, the World Health Organization recommends intermittent preventive treatment of pregnant women (IPTp) with sulfadoxine-pyrimethamine be administered at each ANC visit starting as early as possible in the second trimester. Global IPTp coverage in targeted countries remains unacceptably low. Community delivery of IPTp was explored as a means to improve coverage. METHODS: A cluster randomized, controlled trial was conducted in 12 health facilities in a 1:1 ratio to either an intervention group (IPTp delivered by CHWs) or a control group (standard practice, with IPTp delivered at HFs) in three districts of Burkina Faso to assess the effect of IPTp administration by community health workers (CHWs) on the coverage of IPTp and antenatal care (ANC). The districts and facilities were purposively selected taking into account malaria epidemiology, IPTp coverage, and the presence of active CHWs. Pre- and post-intervention surveys were carried out in March 2017 and July-August 2018, respectively. A difference in differences (DiD) analysis was conducted to assess the change in coverage of IPTp and ANC over time, accounting for clustering at the health facility level. RESULTS: Altogether 374 and 360 women were included in the baseline and endline surveys, respectively. At baseline, women received a median of 2.1 doses; by endline, women received a median of 1.8 doses in the control group and 2.8 doses in the intervention group (p-value < 0.0001). There was a non-statistically significant increase in the proportion of women attending four ANC visits in the intervention compared to control group (DiD = 12.6%, p-value = 0.16). By the endline, administration of IPTp was higher in the intervention than control, with a DiD of 17.6% for IPTp3 (95% confidence interval (CI) - 16.3, 51.5; p-value 0.31) and 20.0% for IPTp4 (95% CI - 7.2, 47.3; p-value = 0.15). CONCLUSIONS: Community delivery of IPTp could potentially lead to a greater number of IPTp doses delivered, with no apparent decrease in ANC coverage.

A Two-Center Randomized Trial of an Additional Early Dose of Measles Vaccine: Effects on Mortality and Measles Antibody Levels.

Background: In addition to protecting against measles, measles vaccine (MV) may have beneficial nonspecific effects. We tested the effect of an additional early MV on mortality and measles antibody levels. Methods: Children aged 4-7 months at rural health and demographic surveillance sites in Burkina Faso and Guinea-Bissau were randomized 1:1 to an extra early standard dose of MV (Edmonston-Zagreb strain) or no extra MV 4 weeks after the third diphtheria-tetanus-pertussis-hepatitis B-Haemophilus influenzae type b vaccine. All children received routine MV at 9 months. We assessed mortality through home visits and compared mortality from enrollment to age 3 years using Cox proportional hazards models, censoring for subsequent nontrial MV. Subgroups of participants had blood sampled to assess measles antibody levels. Results: Among 8309 children enrolled from 18 July 2012 to 3 December 2015, we registered 145 deaths (mortality rate: 16/1000 person-years). The mortality was lower than anticipated and did not differ by randomization group (hazard ratio, 1.05; 95% confidence interval, 0.75-1.46). At enrollment, 4% (16/447) of children in Burkina Faso and 21% (90/422) in Guinea-Bissau had protective measles antibody levels. By age 9 months, no measles-unvaccinated/-unexposed child had protective levels, while 92% (306/333) of early MV recipients had protective levels. At final follow-up, 98% (186/189) in the early MV group and 97% (196/202) in the control group had protective levels. Conclusions: Early MV did not reduce all-cause mortality. Most children were susceptible to measles infection at age 4-7 months and responded with high antibody levels to early MV. Clinical Trials Registration: NCT01644721.

Measuring health workers' motivation composition: validation of a scale based on Self-Determination Theory in Burkina Faso.

BACKGROUND: Although motivation of health workers in low- and middle-income countries (LMICs) has become a topic of increasing interest by policy makers and researchers in recent years, many aspects are not well understood to date. This is partly due to a lack of appropriate measurement instruments. This article presents evidence on the construct validity of a psychometric scale developed to measure motivation composition, i.e., the extent to which motivation of different origin within and outside of a person contributes to their overall work motivation. It is theoretically grounded in Self-Determination Theory (SDT). METHODS: We conducted a cross-sectional survey of 1142 nurses in 522 government health facilities in 24 districts of Burkina Faso. We assessed the scale's validity in a confirmatory factor analysis framework, investigating whether the scale measures what it was intended to measure (content, structural, and convergent/discriminant validity) and whether it does so equally well across health worker subgroups (measurement invariance). RESULTS: Our results show that the scale measures a slightly modified version of the SDT continuum of motivation well. Measurements were overall comparable between subgroups, but results indicate that caution is warranted if a comparison of motivation scores between groups is the focus of analysis. CONCLUSIONS: The scale is a valuable addition to the repository of measurement tools for health worker motivation in LMICs. We expect it to prove useful in the quest for a more comprehensive understanding of motivation as well as of the effects and potential side effects of interventions intended to enhance motivation.

Understanding home delivery in a context of user fee reduction: a cross-sectional mixed methods study in rural Burkina Faso.

BACKGROUND: Several African countries have recently reduced/removed user fees for maternal care, producing considerable increases in the utilization of delivery services. Still, across settings, a conspicuous number of women continue to deliver at home. This study explores reasons for home delivery in rural Burkina Faso, where a successful user fee reduction policy is in place since 2007. METHODS: The study took place in the Nouna Health District and adopted a triangulation mixed methods design, combining quantitative and qualitative data collection and analysis methods. The quantitative component relied on use of data from the 2011 round of a panel household survey conducted on 1130 households. We collected data on utilization of delivery services from all women who had experienced a delivery in the previous twelve months and investigated factors associated with home delivery using multivariate logistic regression. The qualitative component relied on a series of open-ended interviews with 55 purposely selected households and 13 village leaders. We analyzed data using a mixture of inductive and deductive coding. RESULTS: Of the 420 women who reported a delivery, 47 (11 %) had delivered at home. Random effect multivariate logistic regression revealed a clear, albeit not significant trend for women from a lower socio-economic status and living outside an area to deliver at home. Distance to the health facility was found to be positively significantly associated with home delivery. Qualitative findings indicated that women and their households valued facility-based delivery above home delivery, suggesting that cultural factors do not shape the decision where to deliver. Qualitative findings confirmed that geographical access, defined in relation to the condition of the roads and the high transaction costs associated with travel, and the cost-sharing fees still applied at point of use represent two major barriers to access facility-based delivery. CONCLUSIONS: Findings suggest that the current policy in Burkina Faso, as similar policies in the region, should be expanded to remove fees at point of use completely and to incorporate benefits/solutions to support the transport of women in labor to the health facility in due time.

An insecticide-treated bed-net campaign and childhood malaria in Burkina Faso.

OBJECTIVE: To investigate if the first national insecticide-treated bed-net campaign in Burkina Faso, done in 2010, was followed by a decrease in childhood malaria in a district with high baseline transmission of the disease. METHODS: We obtained data on the prevalence of Plasmodium falciparum parasitaemia in children aged 2 weeks to 36 months from malaria surveys in 2009 and 2011. We assessed morbidity in children younger than 5 years by comparing data from the Nouna health district's health management information system before and after the campaign in 2010. We analysed mortality data from 2008 to 2012 from Nouna's health and demographic surveillance system. FINDINGS: The bed-net campaign was associated with an increase in the reported use of insecticide-treated nets. In 2009, 73% (630/869) of children reportedly slept under nets. In 2011, 92% (449/487) did. The campaign had no effect on the proportion of young children with P. falciparum parasitaemia after the rainy season; 52% (442/858) in 2009 and 53% (263/499) in 2011. Cases of malaria increased markedly after the campaign, as did the number of children presenting with other diseases. The campaign was not associated with any changes in child mortality. CONCLUSION: The 2010 insecticide-treated net campaign in Burkina Faso was not associated with a decrease in care-seeking for malaria or all-cause mortality in children younger than 5 years. The most likely explanation is the high coverage of nets in the study area before the campaign which could have had an effect on mosquito vectors, limiting the campaign's impact.

[Factors associated with the poor coverage of Intermittent Preventive Treatment in pregnant women in the Pobè-Adja-Ouèrè-Kétou health zone in Benin]. / Facteurs associés à la faible couverture du Traitement Préventif Intermittent chez les femmes enceintes de la zone sanitaire béninoise de Pobè-Adja-Ouèrè-Kétou.

World Health Organization estimates indicate 216 million malaria episodes in 2010, including 81% in the African region. One of the recommended means of prevention in pregnant women is intermittent preventive treatment, until 2012, two doses of sulfadoxine/pyrimethamine or three doesfor a woman living with HIV In the Pobè-Adja-Ouèrè-Kétou health zone of Benin, coverage ofintermittent preventive treatment remains low (49% against a forecast of 80%) several years after implementation of this strategy. We conducted a cross-sectional study in June and July 2012 to identify factors associated with low intermittent preventive treatment coverage in this area. A total of 339 women were interviewed and 48% ofthem received less than two doses of sulfadoxine pyrimethamine during their prenatal consultations. The variables associated with low intermittent preventive treatment coverage were low antenatal care coverage (p < 0.001) and a prenatal consultation in the private sector (p = 0.039). In the light of our results, actions must be taken by this health zone to encourage women to complete the four visits during pregnancy.

Factors Affecting the Uptake of HIV Testing among Men: A Mixed-Methods Study in Rural Burkina Faso.

BACKGROUND: This study aimed to explore factors shaping the decision to undergo Human Immunodeficiency Virus (HIV) testing among men in rural Burkina Faso. METHODS: The study took place in 2009 in the Nouna Health District and adopted a triangulation mixed methods design. The quantitative component relied on data collected through a structured survey on a representative sample of 1130 households. The qualitative component relied on 38 in-depth interviews, with men purposely selected to represent variation in testing decision, age, and place of residence. A two-part model was conducted, with two distinct outcome variables, i.e. "being offered an HIV test" and "having done an HIV test". The qualitative data analysis relied on inductive coding conducted by three independent analysts. RESULT: Of the 937 men, 357 had been offered an HIV test and 97 had taken the test. Younger age, household wealth, living in a village under demographic surveillance, and knowing that HIV testing is available at primary health facilities were all positively associated with the probability of being offered an HIV test. Household wealth and literacy were found to be positively associated, and distance was found to be negatively associated with the probability of having taken an HIV test. Qualitative findings indicated that the limited uptake of HIV testing was linked to poor knowledge on service availability and to low risk perceptions. CONCLUSION: With only 10% of the total sample ever having tested for HIV, our study confirmed that male HIV testing remains unacceptably low in Sub-Saharan Africa. This results from a combination of health system factors, indicating general barriers to access, and motivational factors, such as one's own knowledge of service availability and risk perceptions. Our findings suggested that using antenatal care and curative services as the exclusive entry points into HIV testing may not be sufficient to reach large portions of the male population. Thus, additional strategies are urgently needed to increase service uptake.

Insecticide-treated mosquito nets in rural Burkina Faso: assessment of coverage and equity in the wake of a universal distribution campaign.

Insecticide-treated mosquito nets (ITNs) are an essential tool of the Roll Back Malaria strategy. An increasing number of African countries have embarked on mass distribution campaigns of long-lasting insecticide-treated nets (LLINs) with the ultimate goal of universal coverage. Such a national campaign with the goal of one ITN for every two people has been conducted in Burkina Faso in 2010. Our aim was to assess the coverage and equity effect of the universal distribution campaign of LLINs in Burkina Faso and to identify determinants of ITN ownership across households after the campaign. We evaluated its effects through comparison of data from two household surveys conducted in early 2010 (before the campaign) and early 2011 (after the campaign) on a representative rural district in north-western Burkina Faso. Data were collected on household characteristics (including socio-economic status) and ITN ownership. We used concentration curves and indices to compare ITN coverage indicators before and after the campaign and multilevel multivariate logistic regression to estimate factors associated with achievement of the universal coverage target in 2011. The survey included 1106 households in 2010 and 1094 in 2011. We found that the proportion of households with at least one ITN increased from 59% before the campaign to 99% afterwards, whereas the concentration index dropped from 0.087 (standard error (SE): 0.014) to 0.002 (SE: 0.002). Fifty-two per cent of households reached the target of one ITN for every two people per household, with the relevant concentration index at -0.031 (SE: 0.016). Eighty-six per cent of households owned at least one ITN for every three people. The main characteristics significantly associated with the targeted intra-household coverage were family size and distance to the health centre but not socio-economic status. In conclusion, despite not having fully met its target, the national LLIN campaign achieved a high level of coverage and fostered equity.

Malnutrition determinants in young children from Burkina Faso.

Childhood malnutrition remains a major challenge to public health in poor countries. Data on malnutrition determinants in African children are scarce. A cross-sectional survey was performed in eight villages of Burkina Faso in June 2009, including 460 children aged 6-31 months. Demographic, socioeconomic, parasitological, clinical and anthropometric characteristics were collected. The main outcome variable was weight-for-length (WFL) z-score (i.e. wasting). A multiple regression model identified village, age group, religion and the presence of younger siblings as significantly associated with wasting. Villages differed in their mean WFL z-score by up to one unit. Compared with younger children, the mean WFL z-score of children aged 24-35 months was 0.63 units higher than the WFL z-score in younger children. This study confirms the still unacceptable high level of malnutrition in young children of rural West Africa and supports the fact that childhood malnutrition is a complex phenomenon highly influenced by contextual variables.

Moving towards universal coverage with malaria control interventions: achievements and challenges in rural Burkina Faso.

This paper reports on a study, which assessed coverage with malaria control interventions in rural Burkina Faso, namely insecticide-treated mosquito nets (ITN) ownership, intermittent preventive treatment (IPTp) for pregnant women and artemisinin-based combination therapy (ACT) for under-five children. The study also addressed the distributional impact of such interventions, with specific reference to equity. The study used data from a representative household survey conducted on 1106 households in the Nouna Health District in 2010. Findings indicated that 59% of all households owned at least one ITN, 66% of all pregnant women received IPT at least once and 34% of under-five children reporting a malaria case were treated with ACT. Multivariate logistic regression revealed that higher socio-economic status, ownership of at least one radio and living in a village within a Health and Demographic Surveillance System were significantly positively associated with ITN, IPTp and ACT coverage. ITN coverage was higher among households in villages, which had previously hosted an ITN trial and/or the most favourable arm of a trial. Comparing current findings with previous estimates suggests that the country has made substantial progress towards scaling up malaria control interventions but that current coverage rates are still far from achieving the universal coverage targets set by the Roll Back Malaria Partnership. In addition, current coverage patterns reveal the existence of multiple inequities across groups, suggesting that current policies are inadequate to achieve equitable scaling up. Future planning of malaria control interventions ought to take into consideration current inadequacies and lead to programmes better designed to overcome them.

The impact of targeted subsidies for facility-based delivery on access to care and equity - evidence from a population-based study in rural Burkina Faso.

We conducted the first population-based impact assessment of a financing policy introduced in Burkina Faso in 2007 on women's access to delivery services. The policy offers an 80 per cent subsidy for facility-based delivery. We collected information on delivery in five repeated cross-sectional surveys carried out from 2006 to 2010 on a representative sample of 1050 households in rural Nouna Health District. Over the 5 years, the proportion of facility-based deliveries increased from 49 to 84 per cent (P<0.001). The utilization gap across socio-economic quintiles, however, remained unchanged. The amount received for all services associated with births decreased by 67 per cent (P<0.001), but women continued to pay on average 1423 CFA (\[euro]1=655 CFA), about 500 CFA more than the set tariff of 900 CFA. Our findings indicate the operational effectiveness of the policy in increasing the use of facility-based delivery services for women. The potential to reduce maternal mortality substantially has not yet been assessed by health outcome measures of neonatal and maternal mortality.

Long-term effects of malaria prevention with insecticide-treated mosquito nets on morbidity and mortality in African children: randomised controlled trial.

OBJECTIVE: The objective is to investigate the effect of malaria control with insecticide-treated mosquito nets (ITNs) regarding possible higher mortality in children protected during early infancy, due to interference with immunity development, and to assess long-term effects on malaria prevalence and morbidity. METHODS: Between 2000 and 2002, a birth cohort was enrolled in 41 villages of a malaria holoendemic area in north-western Burkina Faso. All neonates (n = 3387) were individually randomised to ITN protection from birth (group A) vs. ITN protection from age 6 months (group B). Primary outcome was all-cause mortality. In 2009, a survey took place in six sentinel villages, and in 2010, a census was conducted in all study villages. RESULTS: After a median follow-up time of 8.3 years, 443/3387 (13.1%) children had migrated out of the area and 484/2944 (16.4%) had died, mostly at home. Long-term compliance with ITN protection was good. There were no differences in mortality between study groups (248 deaths in group A, 236 deaths in group B; rate ratio 1.05, 95% CI: 0.889-1.237, P = 0.574). The survey conducted briefly after the rainy season in 2009 showed that more than 80% of study children carried asexual malaria parasites and up to 20% had clinical malaria. CONCLUSION: Insecticide-treated mosquito net protection in early infancy is not a risk factor for mortality. Individual ITN protection does not sufficiently reduce malaria prevalence in high-transmission areas. Achieving universal ITN coverage remains a major challenge for malaria prevention in Africa.

Falciparum malaria in young children of rural Burkina Faso: comparison of survey data in 1999 with 2009.

BACKGROUND: Roll Back Malaria (RBM) interventions such as insecticide-treated mosquito nets (ITN) and artemisinin-based combination therapy (ACT) have become implemented with different velocities in the endemic countries of sub-Saharan Africa (SSA) in recent years. There is conflicting evidence on how much can be achieved under real life conditions with the current interventions in the highly endemic savannah areas of SSA. METHODS: The study took place in a rural area of north-western Burkina Faso, which was defined as holoendemic in 1999. Clinical and parasitological data were compared in two cohorts of young children of the same age range from eight villages. Surveys took place in June and December of the year 1999 and 2009 respectively. RESULTS: Prevalence of mosquito net use increased from 22% in 1999 to 73% in 2009, with the majority of nets being ITNs in 2009. In 2009, P. falciparum prevalence was significantly lower compared to 1999 (overall reduction of 22.8%). CONCLUSIONS: The reduction in malaria prevalence in young children observed between 1999 and 2009 in a rural and formerly malaria holoendemic area of Burkina Faso is likely attributable to the increase in ITN availability and utilization over time.

Determinants of utilisation of maternal care services after the reduction of user fees: a case study from rural Burkina Faso.

OBJECTIVE: To identify determinants of utilisation for antenatal care (ANC) and skilled attendance at birth after a substantial reduction in user fees. METHODS: The study was conducted in the Nouna Health District in north-western Burkina Faso in early 2009. Data was collected by means of a representative survey on a sample of 435 women who reported a pregnancy in the prior 12 months. Two independent logit models were used to assess the determinants of (a) ANC utilisation (defined as having attended at least 3 visits) and (b) skilled assistance at birth (defined as having delivered in a health facility). RESULTS: 76% of women had attended at least 3 ANC visits and 72% had delivered in a facility. Living within 5 km from a facility was positively associated, while animist religion, some ethnicities, and household wealth were negatively associated with ANC utilisation. Some ethnicities, living within 5 km from a health facility, and having attended at least 3 ANC visits were positively associated with delivering in a facility. CONCLUSIONS: User fee alleviation secured equitable access to care across socio-economic groups, but alone did not ensure that all women benefited from ANC and from skilled attendance at birth. Investments in policies to address barriers beyond financial ones are urgently needed.

Different delivery mechanisms for insecticide-treated nets in rural Burkina Faso: a provider's perspective.

BACKGROUND: Insecticide-treated nets (ITNs) have been confirmed to be a very effective tool in malaria control. Two different delivery strategies for roll-out of ITN programmes have been the focus of debate in the last years: free distribution and distribution through commercial marketing systems. They are now seen as complementary rather than opponent. Acceptance of these programmes by the community and involved providers is an important aspect influencing their sustainability. This paper looks at how providers perceived, understood and accepted two interventions involving two different delivery strategies (subsidized sales supported by social marketing and free distribution to pregnant women attending antenatal care services). METHODS: The interventions took place in one province of north-western Burkina Faso in 2006 in the frame of a large randomized controlled ITN intervention study. For this descriptive qualitative study data were collected through focus group discussions and individual interviews. A total of four focus group discussions and eleven individual interviews have been conducted with the providers of the study interventions. RESULTS: The free distribution intervention was well accepted and perceived as running well. The health care staff had a positive and beneficial view of the intervention and did not feel overwhelmed by the additional workload. The social marketing intervention was also seen as positive by the rural shopkeepers. However, working in market economy, shopkeepers feared the risk of unsold ITNs, due to the low demand and capacity to pay for the product in the community. CONCLUSION: The combination of ITN free distribution and social marketing was in general well accepted by the different providers. However, low purchasing power of clients and the resulting financial insecurities of shopkeepers remain a challenge to ITN social marketing in rural SSA.

Comparative cost analysis of insecticide-treated net delivery strategies: sales supported by social marketing and free distribution through antenatal care.

Insecticide-treated nets (ITNs) are effective in substantially reducing malaria transmission. Still, ITN coverage in sub-Saharan Africa (SSA) remains extremely low. Policy makers are concerned with identifying the most suitable delivery mechanism to achieve rapid yet sustainable increases in ITN coverage. Little is known, however, on the comparative costs of alternative ITN distribution strategies. This paper aimed to fill this gap in knowledge by developing such a comparative cost analysis, looking at the cost per ITN distributed for two alternative interventions: subsidized sales supported by social marketing and free distribution to pregnant women through antenatal care (ANC). The study was conducted in rural Burkina Faso, where the two interventions were carried out alongside one another in 2006/07. Cost information was collected prospectively to derive both a financial analysis adopting a provider's perspective and an economic analysis adopting a societal perspective. The average financial cost per ITN distributed was US$8.08 and US$7.21 for sales supported by social marketing and free distribution through ANC, respectively. The average economic cost per ITN distributed was US$4.81 for both interventions. Contrary to common belief, costs did not differ substantially between the two interventions. Due to the district's ability to rely fully on the use of existing resources, financial costs associated with free ITN distribution through ANC were in fact even lower than those associated with the social marketing campaign. This represents an encouraging finding for SSA governments and points to the possibility to invest in programmes to favour free ITN distribution through existing health facilities. Given restricted budgets, however, free distribution programmes are unlikely to be feasible.