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Background  Many studies have assessed the level of bed net coverage in populations at risk of malaria infection. These revealed large variations in bed net use across countries, regions and social strata. Such studies are often aimed at identifying populations with low access to bed nets that should be prioritized in future interventions. However, often spatial differences in malaria endemicity are not taken into account. By ignoring variability in malaria endemicity, these studies prioritize populations with little access to bed nets, even if these happen to live in low endemicity areas. Conversely, populations living in regions with high malaria endemicity will receive a lower priority once a seizable proportion is protected by bed nets. Adequately assigning priorities requires accounting for both the current level of bed net coverage and the local malaria endemicity. Indeed, as shown here for 23 African countries, there is no correlation between the level of bed net coverage and the level of malaria endemicity in a region. Therefore, the need for future interventions can not be assessed based on current bed net coverage alone. This paper proposes the Adjusted Bed net Coverage (ABC) statistic as a measure taking into account both local malaria endemicity and the level of bed net coverage. The measure allows setting priorities for future interventions taking into account both local malaria endemicity and bed net coverage.    Methods  A mathematical formulation of the ABC as a weighted difference of bed net coverage and malaria endemicity is presented. The formulation is parameterized based on a model of malaria epidemiology (Smith  et al . Trends Parasitol 25:511-516, 2009). By parameterizing the ABC based on this model, the ABC as used in this paper is proxy for the steady-state malaria burden given the current level of bed net coverage. Data on the bed net coverage in under five year olds and malaria endemicity in 23 Sub-Saharan countries is used to show that the ABC prioritizes different populations than the level of bed net coverage by itself. Data from the following countries was used: Angola, Burkina Faso, Burundi, Cameroon, Congo Democratic Republic, Ethiopia, Ghana, Guinea, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Namibia, Nigeria, Rwanda, Senegal, Sierra Leone, Tanzania, Uganda, Zambia and Zimbabwe. The priority order given by the ABC and the bed net coverage are compared at the countries’ level, the first level administrative divisions and for five different wealth quintiles.    Results  Both at national level and at the level of the administrative divisions the ABC suggests a different priority order for selecting countries and divisions for future interventions. When taking into account malaria endemicity, measures assessing equality in access to bed nets across wealth quintiles, such as slopes of inequality, are prone to change. This suggests that when assessing inequality in access to bed nets one should take into account the local malaria endemicity for populations from different wealth quintiles.    Conclusion  Accounting for malaria endemicity highlights different countries, regions and socio-economic strata for future intervention than the bed net coverage by itself. Therefore, care should be taken to factor out any effects of local malaria endemicity in assessing bed net coverage and in prioritizing populations for further scale-up of bed net coverage. The ABC is proposed as a simple means to do this that is derived from an existing model of malaria epidemiology.

An adjusted bed net coverage indicator with estimations for 23 African countries