© WHO, S. Hollyman. A woman hangs a mosquito net in the temporary dwelling in the fields (champka) that she and her husband are clearing to farm, Cambodia.
©WHO Kisimu, Kenya

The impact of research for implementation: a series of case studies.

This is one of several case studies illustrating the scope and impact of “research for implementation.” These were originally published in the report, Bridging the gaps in malaria R&D: An analysis of funding—from basic research and product development to research for implementation. It summarized the findings of a pilot study comparing this field to funding for basic research and product development.

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Case study 1: Drug packaging increases access to malaria treatment
Case study 2: Reducing deaths with bednets
Case study 3: Two approaches to managing fever, a symptom shared by three diseases—malaria, pneumonia, and diarrhea
Case study 4: Ensuring appropriate health care use during malaria vaccine introduction
Case study 5: Reaching malaria elimination through strengthened national research capacity
Case study 6: Increasing access to new insecticidal products



Research conducted in the 1990s showed that using insecticide-treated bednets reduced childhood mortality by up to 33%.1,2 It was a game-changing finding, but it led to a new question: How could these bednets be scaled up to millions across all the countries at risk for malaria?3
In 1999, the United Nations Children’s Fund and World Health Organization set the goal of providing 32 million bednets and 320 million bednet treatments per year for the following ten years to protect 80% of African households against malaria.4



Ensuring access to millions required work on many fronts. A number of research studies provided solutions to the many challenges to scale-up; these included the cost, availability, practicality, and acceptability of bednets in different settings. A few examples illustrate the range of studies that fall under research for implementation.
Helping people understand the value of the bednets was a first critical challenge,5,6 which included motivating them to get the nets, care for them, and use them. Social research identified the motivators—it was not so much a concern about malaria but about the nuisance of being bitten by mosquitoes. That knowledge was built into educational materials, focused on giving families peace from the mosquitoes.7
Even the color and shape of the nets became a research topic.8,9 Scientists found that the color affected how often nets were washed (more frequent washing reduced the effectiveness of the nets) and even whether they were used.
The insecticide needed to be re-applied to the bednets. In Tanzania, communal “dipping days,” when nets were dipped in insecticide, were not working. A study thoroughly tested a set of instructions for safe and effective use of the treatment kits, even where literacy was low, in both urban and rural communities. The instructions were adopted by two social marketing projects. “Dipping it yourself” became the new way to have bednets effectively used.10
In The Gambia, the government introduced the National Impregnated Bednet Programme in 1992. A study examined the impact of a variety of activities, such as sensitization sessions, an educational campaign, staff training, and supply ordering and distribution. At the end of five months, overall bednet use was 73% and 83% of the nets had the correct amount of insecticide. More importantly, 25% fewer children between the ages of 1 and 9 died within the first year of intervention.11
Costs for the bednets and the insecticides became a concern. People could not afford them, so how could their provision free of charge be justified?12,13 Research showed that the economic losses from malaria would be reduced by 37% over a three-year period in Malawi, while in Cameroon, a 9% to 11% reduction in the need for care was expected—justifying free distribution.14 In The Gambia, research showed that distributing free insecticide through maternal and child health visits would reach the most vulnerable—young children—and that sales through private shops could reach others.15
In Latin America, research investigated the role of community and found that the local manufacture of bednets and their sale through village health workers, even in communities with low cash income, were viable ways of increasing bednet coverage.16



Today, bednets are attributed with saving millions of lives. Since 2000, 663 million cases of malaria have been prevented due to the combined effect of all approaches, with bednets contributing to 68% of the impact.17 Research for implementation—using a broad range of approaches encompassing implementation, operational, social, and economic research—took what was identified as a very effective tool and leapfrogged over deep systemic and logistical challenges to get it into the homes of millions of the most vulnerable across the world. The evidence generated by research for implementation was critical to mobilizing the funding for free bednets, expanding distribution schemes, generating investments in the diversity of products now available, and increasing capacity to continue these efforts at all levels.
© WHO, Kisimu, Kenya.<br /> © WHO, S. Hollyman. A man and his mosquito bednet, United Republic of Tanzania.

©WHO/TDR, Community members build low-cost window and door screens in Colombia.

1. Megatrials show impregnated mosquito nets could save 500,000 African children a year—at very low cost. TDR News. 1996;(50):1-2. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12348836.
2. D’Alessandro U, Olaleye BO, McGuire W, Langerock P, Bennett S, et al. Mortality and morbidity from malaria in Gambian children after introduction of an impregnated bednet programme, The Lancet. 1995;345(8948):479-483. Available at: https://www.ncbi.nlm.nih.gov/pubmed/7861874.
3. Lengler C, Snow CR. From efficacy to effectiveness: insecticide-treated bednets in Africa. Bulletin: World Health Organization. 1996;74(3):325-332. Available at: https://www.ncbi.nlm.nih.gov/pubmed/8789931.
4. Ehiri JE, Anyanwu EC, Scarlett H. Mass use of insecticide-treated bednets in malaria endemic poor countries: public health concerns and remedies. Journal of Public Health Policy. 2004;25(1):9-22. Available at: https://www.ncbi.nlm.nih.gov/pubmed/15134129.
5. Makungu C, Stephen S, Kumburu S, Govella NJ, Dongus S, et al. Informing new or improved vector control tools for reducing the malaria burden in Tanzania: a qualitative exploration of perceptions of mosquitoes and methods for their control among the residents of Dar es Salaam. Malaria Journal. 2017;16(410). Available at: https://malariajournal.biomedcentral.com/articles/10.1186/s12936-017-2056-9.
6. Galvin KT, Patford N, Ajose F, Davies D. An exploratory qualitative study on perceptions about mosquito bednets in the Niger Delta: What are the barriers to sustained use? Journal of Multidisciplinary Healthcare. 2011;4:73-83. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3084309/.
7. Curtis V, Kanki B. Bednets and malaria. Africa Health. 1998;20(4):22-23. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12293744
8. Mutuku FM, Khambira M, Bisanzio D, Mungai P, Mwanzo I, et al. Physical condition and maintenance of mosquito bed nets in Kwale County, coastal Kenya. Malaria Journal. 2013;12(46). Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3572415/
9. Ng`ang`a P, Jayasinghe G, Kimani V, Shililu J, Kabutha C. et al. Bednet use and associated factors in a rice farming community in Central Kenya. Malaria Journal. 2009;8(64). Available at: https://link.springer.com/article/10.1186%2F1475-2875-8-64
10.World Health Organization (WHO) Special Programme for Research andTraining in Tropical Diseases. Tropical Disease Research Progress 1997-1998: Fourteenth Programme Report. Geneva: WHO/TDR; 1999. Available at: http://apps.who.int/iris/
11. Cham MK, D`Alessandro U, Todd J, Bennett S, Fegan G, et al. Implementing a nationwide insecticide impregnated bednet programme in The Gambia. Health Policy Plan. 1996;11(3):292-298. Available at: https://www.ncbi.nlm.nih.gov/pubmed/10160374
12. Binka FN and Adongo P. Acceptability and use of insecticide impregnated bednets in northern Ghana. Tropical Medicine International Health. 1997;2(5):499-507. Available at: https://www.ncbi.nlm.nih.gov/pubmed/9217706
13. D’Alessandro U and Coosemans M. Is it feasible to give insecticide-treated bednets free to pregnant women? The Lancet. 2003;362(9395):151-1516. Available at: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)14778-2/abstract
14. Brinkmann U, Brinkmann A. Economic aspects of the use of impregnated mosquito nets for malaria control. Bulletin: World Health Organization. 1995;73(5): 651-658. Available at: https://www.ncbi.nlm.nih.gov/pubmed/8846491
15. Muller O, Cham K, Jaffar S, Greenwood B. The Gambian National Impregnated Bednet Programme: evaluation of the 1994 cost recovery trial. Social Science and Medicine. 1997;44(12):1903-1909. Available at: https://www.ncbi.nlm.nih.gov/pubmed/9194251
16. Kroger A, Meyer R, Mancheno M, Gonzalez M, Pesse K. Operational aspects of bednet impregnation for community-based malaria control in Nicaragua, Ecuador, Peru and Colombia. Tropical Medicine International Health. 1997;2(6):589-602. Available at: https://www.ncbi.nlm.nih.gov/pubmed/9236827
17. Bhatt S, Weiss DJ, Cameron D, Bisanzio B, Mappin Y, et al. The effect of malaria control on Plasmodium falciparum in Africa between 2000 and 2015. Nature. 2015;526:207-211. Available at: https://www.nature.com/articles/nature15535