In Kisumu County, a pregnant woman named Grace Achieng’ walks to a small pharmacy and spends roughly 300 Kenyan shillings—about US$2.50—on a long-lasting insecticidal net. Across town, a community health volunteer hands out the same type of net for free to mothers who brought their children for vaccination. Grace’s net is identical in quality to the free one, but she paid for it because the distribution campaign had passed her neighborhood months before she learned she was pregnant. Kenya’s malaria prevention efforts face a persistent challenge: public programs distribute millions of nets each year, yet a substantial fraction of the people who need them most—pregnant women in malaria-endemic zones—end up buying their own.

A Tale of Two Bednets: Free Distribution Meets Private Purchase

Kenya’s National Malaria Control Program has run mass net distribution campaigns roughly every three years since the early 2000s, aiming for universal coverage—one net for every two people in a household. These campaigns are funded by a mix of domestic resources and international donors, including the Global Fund and the U.S. President’s Malaria Initiative. By 2023, the campaigns had distributed over 100 million nets nationwide, according to program reports. Campaigns go door-to-door or set up distribution points at health facilities, give nets to anyone who lives in a malaria-risk area, and encourage consistent use.

Yet the net ownership gap persists. Demographic and Health Survey data from 2022 indicate that roughly 80% of households in malaria-endemic counties own at least one net, but ownership among pregnant women—the group for whom the World Health Organization recommends net use from the first antenatal visit through delivery—is lower, estimated at 60–70%. The difference is not trivial. Pregnancy reduces a woman’s immune response to malaria, making her more susceptible to severe disease, anemia, and poor birth outcomes such as low birth weight and stillbirth. An infected mother can also pass the parasite to her fetus.

The free nets, when they arrive, are a marvel of logistics. But they arrive on a schedule tied to campaign cycles, not to individual pregnancies. A woman who becomes pregnant in the second year of a three-year campaign cycle may find that her household’s free nets are worn or lost, and no new distribution is imminent. She then faces a choice: buy a net from a private retailer or go without. Ethnographic studies in Kisumu and other high-burden areas document that many women choose to purchase nets, spending money that might otherwise go toward food or transport to a clinic.

This pattern creates a two-tier system where wealthier women—those with cash on hand—can buy nets early in pregnancy, while poorer women delay or skip purchase, increasing their malaria risk. The policy paradox is clear: a publicly funded program designed to be universal ends up being less accessible to those who need it most, because the program’s timing does not align with individual need.

Why Pregnant Women Pay: Gaps in Program Design

Mass campaigns typically distribute nets through child health clinics, schools, or community gatherings, not through antenatal care services. A pregnant woman attending her first antenatal visit at eight weeks may not receive a net unless the health facility happens to have a stockpile. Many facilities do not, because campaign nets are intended for household-level distribution, not for continuous supply to clinics.

Timing is a persistent issue. Campaigns often occur during the dry season to facilitate logistics, but malaria transmission peaks during and after the rainy season. If a woman becomes pregnant just after a campaign ends, she may have to wait two to three years for the next distribution. Stockouts of nets at health facilities are common, even when the country has a surplus in warehouses. Supply chain delays, last-mile distribution problems, and weak inventory management mean that nets meant for pregnant women sometimes sit in district stores while women pay out-of-pocket at private shops.

The cost of a private net is modest by global standards—typically US$2 to $5—but for a household living on less than $2 per day, that sum can be prohibitive. In a 2021 study in western Kenya, researchers found that women in the lowest wealth quintile were half as likely to own a treated net as those in the highest quintile, even after controlling for region and parity. The same study noted that women who purchased nets did so an average of two months later in pregnancy than those who received free nets, meaning they spent a longer period unprotected.

Wealthier women, by contrast, can afford to buy nets early and often. They may also have better access to information about when and where to buy. This pattern is not unique to Kenya; similar disparities have been documented across sub-Saharan Africa, where mass distribution campaigns achieve high coverage on paper but leave vulnerable subpopulations behind.

The Equity Gradient: Wealth, Geography, and Malaria Risk

Kenya’s malaria burden is concentrated in the western and coastal regions, where transmission is perennial. Counties like Kisumu, Siaya, Homa Bay, and Migori have the highest prevalence, with rates among pregnant women estimated at 8–15% as of 2023, according to the Kenya Malaria Indicator Survey. In these same counties, net ownership is highest—but so is the gap between rich and poor. The poorest households, often in remote rural areas, are less likely to be reached by campaign distributions and less able to buy nets privately.

Urban slums present a different challenge. In informal settlements like Kibera in Nairobi, malaria risk is lower than in rural endemic zones, but still significant. Pregnant women in these areas may not be prioritized by campaigns focused on high-burden rural counties. They also face high costs for nets relative to their income. Out-of-pocket spending on nets can divert funds from other essentials, such as nutrition or antenatal care attendance. A 2020 study in Kibera found that women who purchased nets reported cutting back on food purchases to afford them.

Interviews in Kisumu provide a granular view of these trade-offs. Women describe weighing the cost of a net against the cost of treating malaria if they or their child fall ill. One woman told interviewers, “If I buy a net, I have to skip buying vegetables for a week. But if I get malaria, I will spend more on medicine and lose days of work.” The decision is not simply about health; it is about household economics. For the poorest women, the calculus often favors delaying purchase until symptoms appear, by which time the parasite may already have affected the pregnancy.

County-level data from the Kenya Health Information System reveal inequities in net distribution. Some counties report distributing nets to more than 100% of target households—likely due to overcounting—while others fall below 60%. The variation does not always correlate with malaria prevalence. Political factors, local leadership, and donor attention all play a role. A county with a strong health management team may secure more nets than a neighboring county with a weaker one, even if both have similar need.

Programmatic Fixes That Could Close the Gap

Several evidence-based interventions could reduce the number of pregnant women who must buy nets. The most straightforward is integrating net distribution into routine antenatal care. Instead of relying on mass campaigns, health facilities could provide a free net to every pregnant woman at her first antenatal visit, regardless of campaign timing. This approach has been piloted in a few counties, with promising results. In one pilot in Migori County, net coverage among pregnant women rose from 62% to 91% within a year.

Another option is the use of electronic vouchers, or e-vouchers, that pregnant women can redeem at private pharmacies for a subsidized net. This leverages the private sector without requiring out-of-pocket payment at full price. A pilot in Tanzania showed that e-vouchers increased net ownership among pregnant women by 25 percentage points. Kenya could adapt this model using mobile money platforms like M-Pesa, which are widely used even in rural areas.

Targeted campaigns in high-burden sub-counties could also help. Instead of blanket distributions every three years, programs could conduct more frequent, smaller-scale campaigns in areas with low coverage or high malaria incidence. This would require better real-time data on net ownership and malaria cases, which many counties lack. Strengthening health information systems is a prerequisite for any targeted approach.

Linking net distribution to intermittent preventive treatment in pregnancy (IPTp) is another logical step. IPTp—a course of antimalarial drugs given at antenatal visits—is already standard in Kenya. If a woman receives IPTp but no net, the protection is incomplete. Combining the two interventions at the same visit would be efficient and could be reinforced by community health workers who remind women to bring their nets to appointments.

Other countries offer lessons. Rwanda has achieved some of the highest net coverage rates in Africa through a combination of mass campaigns and continuous distribution at health facilities. Community health workers in Rwanda are responsible for tracking pregnant women in their villages and ensuring they receive a net early in pregnancy. Kenya’s community health volunteer program, while extensive, does not have the same systematic focus on pregnant women. Training and incentivizing these volunteers to prioritize net distribution for pregnant women could yield rapid gains.

What the Evidence Says About Cost-Effectiveness

Investing in closing the net gap is not only a matter of equity; it is also cost-effective. Modeling studies by the Kenya Medical Research Institute (KEMRI) suggest that every US$1 spent on bednets saves roughly US$3 to $6 in treatment costs for malaria. This is because preventing a case of malaria is far cheaper than treating one, especially when severe illness or hospitalization is involved. For pregnant women, the savings are even larger when accounting for neonatal complications and low birth weight.

Subsidizing private-sector nets through vouchers or continuous distribution at antenatal clinics would be more expensive than mass campaigns on a per-net basis, but the incremental cost is modest. A 2022 cost-effectiveness analysis in The Lancet Global Health estimated that adding facility-based net distribution for pregnant women would cost about US$8 per disability-adjusted life year (DALY) averted, well below the threshold considered very cost-effective in low-income settings. The same analysis found that private purchase subsidies would be similarly cost-effective, especially if targeted to the poorest women.

Donor-funded nets are cheaper than those purchased out-of-pocket, because bulk procurement and long-term contracts drive down unit costs. The Global Fund pays roughly US$2 per net, while a woman in a Kenyan pharmacy may pay $3 to $5 for the same product. The difference is a markup that covers transport, retail margin, and taxes. From a societal perspective, it would be cheaper to give nets away than to have women buy them. Yet the current system effectively transfers the cost to the most vulnerable.

The investment case for universal coverage remains strong. A 2021 KEMRI-led modeling exercise projected that achieving 80% net use among pregnant women in endemic counties could reduce maternal malaria cases by 20% and neonatal deaths by 12%. These gains would require not only more nets but also sustained behavioral campaigns to ensure nets are used every night, not just during pregnancy. Some nets are diverted for fishing or other uses, a problem that no distribution strategy has fully solved.

From Policy to Practice: Closing the Implementation Chasm

Kenya’s National Malaria Strategy 2021–2025 sets a target of 80% net use among pregnant women, up from the current 60–70%. Achieving that target will require more than policy documents. County health teams need real-time data on net stock and distribution so they can redirect supplies to facilities with low coverage. Many counties still rely on paper registers and monthly reports that are weeks out of date. Digital tools, such as the DHIS2 platform used by the Ministry of Health, could be adapted to track net distribution at the facility level, but adoption has been uneven.

Community health volunteers are the frontline of malaria prevention in many areas. They conduct home visits, distribute nets during campaigns, and educate families about use. Yet their work is often unpaid or minimally compensated, leading to high turnover and low motivation. A 2023 evaluation of the community health volunteer program in western Kenya found that volunteers spent only 15% of their time on malaria-related activities, partly because they were tasked with multiple health areas. Focusing their role on pregnant women and net distribution, with performance-based incentives, could improve outcomes.

Political will and budget allocation ultimately determine success. Malaria control in Kenya is funded largely by international donors, who have maintained support but face competing priorities. Domestic financing for nets has increased in recent years, but remains a small share of the total. In the 2023/24 budget, the national government allocated roughly US$10 million for malaria commodities, while donors contributed over US$50 million. Sustaining and expanding net distribution will require a long-term commitment from both sources.

Different views exist on the best path forward. Some argue that mass campaigns are the most efficient way to achieve high coverage quickly, and that the gaps for pregnant women can be addressed with small adjustments rather than a system overhaul. Others contend that continuous distribution through health facilities is the only way to ensure every pregnancy is protected, even if it costs more to administer. The evidence supports elements of both views: campaigns achieve scale, but facility-based distribution reaches individuals at the right time.

Similar patterns appear in other areas of maternal health, where public programs provide essential services but leave gaps that private purchases must fill—as seen in Thailand, where patients with diabetes in public clinics face rationing while private patients get advanced insulin pumps. The underlying issue is the same: program design that does not account for the timing and diversity of individual needs.

For Grace Achieng’ and the thousands of women like her, the question is whether the system can adapt before her next pregnancy. If Kenya’s health system can integrate net distribution into antenatal care, use data to target high-need areas, and empower community health workers, the purchase she made at the pharmacy could become a relic of a less equitable past. But achieving that will require sustained attention to the details of implementation—the kind of attention that is harder to fund than a mass campaign, but no less essential.

This article is for informational purposes only and does not constitute medical advice. Individual health decisions should be made in consultation with a qualified healthcare provider.