Simon I Hay

Public health has a mobilisation problem

The past decade has transformed public health. We can measure health loss with unprecedented precision, identify its causes and risks, and expose inequalities between and within populations. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) exemplifies this progress:1 its latest cycle estimates the burden of 375 diseases and injuries and 88 modifiable risks across 204 countries and territories.2

Tracking development assistance for health, 1990–2030: historical trends, recent cuts, and outlook

Development assistance for health (DAH) rose to its highest levels during the COVID-19 pandemic but has since reduced amid rising global economic uncertainty and competing fiscal demands. In early 2025, major donors including the USA and the UK announced substantial reductions in aid, prompting concerns about the future of health financing in middle- and low-income countries. To date, no comprehensive assessment has quantified the effects of these announced cuts on overall DAH levels or its future trajectories. Methods We estimated DAH from 1990 to 2030, drawing from a wide range of data sources including the Organisation for Economic Co-operation and Development Creditor Reporting System database, online databases of agencies such as The Global Fund to Fight AIDS, Tuberculosis, and Malaria and the Global Alliance for Vaccines and Immunization (Gavi), and financial reports from private philanthropies and non-governmental organisations. Disbursements were categorised by source, disbursing agency, health focus area, and recipient country using standardised keyword tagging methods developed over the 15 years of Institute for Health Metrics and Evaluation Financing Global Health reports. For 2025, we incorporated budget cuts announced by major donors to develop preliminary estimates. Forecasts to 2030 used donor-specific funding targets and linear regression models. Additional refinements for this iteration of our DAH tracking included expanded donor coverage and disaggregation of health areas for additional disbursing entities. Findings DAH peaked at US$80.3 billion in 2021 and fell to $49.6 billion in 2024. In 2025, announced budget cuts—particularly reductions in US bilateral aid—are expected to contribute to further declines in global DAH to $38.4 billion, levels last seen in 2009. Key global health institutions (e.g., Foreign, Commonwealth & Development Office and US Agency for International Development and Agence Française) providing DAH fighting key infectious diseases and providing childhood vaccines will contract their own disbursements. Because the key multilateral development banks have been protected from the major funding cuts, the World Bank has increased its relative share of total DAH disbursements. Forecasts indicate continued stagnation in DAH through 2030 under current policies, reaching $36.2 billion in 2030. Our sensitivity analyses suggest that our estimate for 2025 could range from $36.8 billion in a pessimistic scenario to $40.0 billion in an optimistic scenario based on changes in US cuts. Similarly, in the next five years, total DAH is expected to reach $37.8 billion in 2030 under a positive scenario for US contribution and $34.5 billion under a negative scenario for US contribution. Interpretation The global health financing landscape is entering a period of sustained cuts. Major reductions in DAH, particularly from historically leading donors, threaten to widen health disparities unless mitigated by increased domestic resource mobilisation or alternative financing mechanisms. This study highlights the urgent need for greater efficiency, strategic reprioritisation, and strengthened fiscal resilience in recipient countries to safeguard the substantial global health gains of the previous three decades.

AUG 2015MurraySocio-Environmental Systems Modeling

Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition

Background The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age–sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development. Methods We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time. Findings Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6–6·6), from 65·3 years (65·0–65·6) in 1990 to 71·5 years (71·0–71·9) in 2013, HALE at birth rose by 5·4 years (4·9–5·8), from 56·9 years (54·5–59·1) to 62·3 years (59·7–64·8), total DALYs fell by 3·6% (0·3–7·4), and age-standardised DALY rates per 100¿000 people fell by 26·7% (24·6–29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non–communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries. Interpretation Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition—in which increasing sociodemographic status brings structured change in disease burden—is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

The Lancet Commission on 21st century global threats to health

Causes of death across the life course in the Association of Southeast Asian Nations (ASEAN): a systematic analysis for the Global Burden of Disease Study 2023

BACKGROUND: The drivers of mortality and their associated risk factors evolve throughout the course of life. Understanding these transitions is essential for effective, equitable, and age-appropriate health interventions. METHODS: As part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023, we examined life expectancy and the probability of death from birth to age 70 years (70q0) from 1990 to 2023 for each Association of Southeast Asian Nations (ASEAN) member state. In addition, we assessed causes of death and risk factor by age and sex across different life stages. Life expectancy was estimated from age-specific mortality rates with standard demographic techniques, and 70q0 from mortality and GBD life tables. Cause-specific mortality was estimated using the Cause of Death Ensemble model, and risk-attributable mortality using the comparative risk assessment framework. FINDINGS: In 2023, regional life expectancy was 70·1 years (95% uncertainty interval 69·6-70·7) for males and 76·2 years (75·7-76·7) for females, ranging from 87·5 years (87·3-87·8) for females in Singapore to 62·1 years (60·8-63·5) for males in Myanmar. Correspondingly, all-cause 70q0 was higher for males than for females. Neonatal disorders were the leading cause of mortality among infants younger than 1 year. Road injuries were the primary driver of mortality among males from adolescence through to early adulthood, accounting for 25·0% (17·0-31·0) of total mortality (8230 [5740-10 800] deaths) in males aged 15-19 years, with mortality rates varying from 3·0 per 100 000 population (2·3-3·7) to 49·0 per 100 000 population (25·0-67·1) between countries. Among females, maternal disorders were the leading cause of death in ages 25-34 years. In mid-adulthood, non-communicable diseases such as ischaemic heart disease and stroke emerged as major causes. Tobacco use was the dominant risk factor across most of adulthood in males, whereas high blood pressure was the prevailing risk factor among adult females. INTERPRETATION: Although the leading causes of death have converged across countries, the outcomes of these causes remain divergent, reflecting persistent inequalities across the region. These patterns present a strategic opportunity for multilateral action to mobilise collective resources and achieve regional health equity.

Assessing methodological differences in estimating exposure to intimate-partner violence against women in Brazil: a multi-source observational analysis

Observational analysis reveals wide variation in intimate partner violence estimates among Brazilian women, highlighting the critical impact of measurement methods on reported prevalence.

Global, regional, and national trends in the morbidity gap and contributing diseases, injuries, and risk factors, 1990–2023: a systematic analysis for the Global Burden of Disease Study 2023

Systematic analysis estimates changes in the morbidity gap in various populations, highlighting health trends and risks.

Health effects associated with alcohol consumption: a Burden of Proof study

The relationship between alcohol and health is complex, and the evidence relating alcohol consumption to various cardiovascular diseases, cancers and other conditions is evolving. Moreover, alcohol drinking guidelines vary widely. Here we conducted 16 systematic reviews across four databases and conservatively re-evaluated dose–response relationships between alcohol consumption and 20 health outcomes, analysing 843 cohort and case–control studies using the Burden of Proof meta-analytic framework. We found that levels of current alcohol consumption are associated with increased risks for cancers of the breast, colorectum, oesophagus, larynx, lip and oral cavities, pharynx, liver, stomach, pancreas and prostate, as well as pancreatitis, cirrhosis and other chronic liver diseases, lower respiratory infections, tuberculosis, and atrial fibrillation and flutter. We found J- or U-shaped relationships between alcohol consumption and type 2 diabetes, Alzheimer’s disease and other dementias, ischaemic heart disease, ischaemic stroke and haemorrhagic stroke. While potential health impacts at low-to-moderate levels varied by outcome, high levels of alcohol consumption were associated with increased risk across all outcomes.

The plight of the Monaco microstate in the GBD 2023 study – Authors' reply

Risk and Protective Factors Associated With HIV-Related Mortality in Children Receiving Antiretroviral Therapy

Model-based meta-regression identifies modifiable risk and protective factors influencing HIV mortality in children receiving ART.

Measuring antenatal care timing and content across 131 low-income and middle-income countries, 1995–2023: a systematic analysis of trends

BACKGROUND: Timely and comprehensive antenatal care can improve maternal and perinatal health by enabling early detection and treatment of pregnancy complications. We estimated the content and timing of antenatal care visits for 131 low-income and middle-income countries (LMICs) from 1995 to 2023. METHODS: We systematically identified population-representative data sources capturing antenatal care timing and content. We selected five widely measured indicators of antenatal care screening and prevention services: iron supplementation, measurement of weight and blood pressure, and provision of blood and urine samples. We modelled the proportion of women with a livebirth reporting all five items (antenatal care content proportion), mean number of items reported (antenatal care content mean), proportion with first trimester antenatal care attendance, and mean number of antenatal care visits using spatiotemporal Gaussian process regression. FINDINGS: Across LMICs, the proportion of women with a livebirth who initiated antenatal care in the first trimester increased from 46·2% (95% uncertainty interval 42·2-49·9) in 1995 to 63·7% (62·8-64·5) in 2023, and the average number of antenatal care visits during pregnancy rose from 3·7 (3·4-4·0) to 6·0 (5·9-6·1). In 2023, 69·3% (68·4-70·1) of women with a livebirth received all five antenatal care items, a major increase from 1995 (25·9% [24·1-27·8]). In 2023, the proportion of women who attended antenatal care but did not receive all five items (26·2% [25·5-27·0]) exceeded those who did not attend antenatal care at all (7·1% [6·5-8·1]). The receipt of all five items also varied by geography: 79·2% (77·6-80·5) in Latin America and the Caribbean received all five items, compared with 59·8% (58·4-60·9) of women in sub-Saharan Africa. INTERPRETATION: Despite improvements in the receipt of basic elements of antenatal care from 1995 to 2023, health systems continue to miss opportunities to deliver important care to women who attend antenatal care. The identified gaps in coverage should be targeted for improvement to support receipt of timely and effective health care that improves maternal and neonatal health.

Burden of cancer attributable to occupational asbestos exposure in the Americas, 1990–2023: an analysis using the Global Burden of Disease Study 2023

This analysis reveals rising cancer rates linked to occupational asbestos among women in the Americas, indicating urgent health policy action is needed.

Burden of disease and life expectancy decomposition in Brazil and its federated units, 1990–2023: an analysis based on the global burden of disease study 2023

Background: Understanding mortality, morbidity, and life expectancy (LE) patterns in Brazil subsidies public health decisions. We analysed changes in the burden of disease from 1990 to 2023 and investigated the impact of the COVID-19 pandemic throughout Brazil and its federated units (FUs). Methods: We estimated all-cause and cause-specific mortality, morbidity, risk factors, and LE from 1990 to 2023, for Brazil and its 27 FUs. To compare estimates before (1990-2019), during (2019-2021), and after (2021-2023) the COVID-19 pandemic. Findings: All-cause age-standardised mortality and disability-adjusted life-year (DALY) rates reduced from 1990 to 2023 (-34.5% [95% uncertainty interval -35.3 to -33.8] and -29.5% [-32.3 to -26.9]), respectively. This reduction reversed between 2019 and 2021 with an increase in all-cause age-standardised mortality (27.6% [26.7, 28.6]) and DALY (18.3% [16.3, 20.5]) rates. The magnitude of changes in these rates varied largely within Brazil. During the pandemic, most of the FUs had an increase in mortality of over 20%. In 2023, total all-cause age-standardised mortality rates returned to the level observed before the pandemic. In 2019, the main underlying causes of death were ischaemic heart disease, stroke and lower respiratory infection. In 2021, the leading cause of deaths and DALY shifted to COVID-19. In 2023, the main causes returned to the 2019 ranking. LE increased 7.01 years from 1990 to 2019, but decreased 3.4 years in the pandemic period, resulting in 7.18 years of increment from 1990 to 2023. Interpretation: The pattern of LE increase and reductions in the leading causes of death from 1990 to 2019, was disrupted by the COVID-19 pandemic. The adverse effects of this health crisis on the burden of disease and LE were heterogeneous within the country. These findings reveal the strength and resilience of the public health system, but reinforces the need to focus on equity and preparedness for future health emergencies. Funding: Gates Foundation and the Brazilian Ministry of Health. TED 67/2023. Health and Environment Surveillance Secretariat, Ministry of Health, Brazil.

Location of births by health facility type: a time trend analysis from 1995 to 2023 in 130 low- and middle-income countries

Background: With major increases in facility births in low- and middle-income countries (LMICs) since 1995, a key question is what types of facilities met the increased demand. Understanding the evolving delivery landscape is crucial to informing debates about optimal models for balancing access, quality, and equity. We studied the distribution of delivery location by health facility level and sector (private versus public) in 130 LMICs from 1995 to 2023. Methods: We used 745 data sources with delivery location information in our analysis. We first categorised births as in-facility or not, then further classified facility births by level (hospital or lower-level) and sector (public or private). We used spatiotemporal Gaussian process regression to model the share of births by facility type from 1995 to 2023 and compared delivery patterns to development and health indicators. Findings: In 2023, 47.5% (95% uncertainty interval [UI] 46.4-48.6) of deliveries in LMICs were in public hospitals, 19.2% (18.3-20.2) were in private hospitals, 13.0% (12.3-13.8) were in lower-level public facilities, 2.0% (1.9-2.2) were in private lower-level facilities, and the remaining 18.2% (17.3-19.2) were outside health facilities. In 106 countries, more than half of deliveries were in public hospitals, while in 12 countries, public lower-level facilities provided care for more than half of births. In only two countries were private hospitals used for more than half of births, while in the remaining ten countries no facility type provided the majority of care. Between 1995 and 2023, nearly two-thirds (62.1%) of the 41.0 percentage-point increase in facility births was borne by public hospitals. Delivery in lower-level facilities was more common in countries with lower levels of development and higher neonatal mortality rates. Interpretation: The mix of delivery locations represents the diversity of health systems worldwide. Our analysis highlights the pivotal and growing role of public hospitals in delivery care, though public lower-level delivery care is common in high-mortality contexts. Policy makers should account for the facility mix and the complex roles of public and private sectors when designing strategies to improve maternal and perinatal outcomes.

Adverse maternal and neonatal outcomes associated with hemoglobin concentration in pregnancy: a Burden of Proof study

This Burden of Proof study reveals links between hemoglobin levels and adverse maternal and neonatal outcomes, suggesting the need for tailored policies.

The global, regional, and national burden attributable to low bone mineral density, 1990–2020: an analysis of a modifiable risk factor from the Global Burden of Disease Study 2021

BACKGROUND: Fractures related to osteoporosis and low bone mineral density lead to substantial morbidity, mortality, and cost to individuals and health systems. Here we present the most up-to-date global, regional, and national estimates of the contribution of low bone mineral density to the burden of fractures from falls and additional categories of injuries from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021. METHODS: ). The population-attributable fraction for low bone mineral density was calculated by comparing the observed distributions of standardised femoral neck bone mineral density to an age-specific and sex-specific counterfactual distribution, defined as the 99th percentile of five rounds of the National Health and Nutrition Examination Survey in the USA, by 5-year age group and sex. Hospital and emergency department data were used to derive the incidence of fractures for six categories of injury (road injuries, other transport injuries, falls, non-venomous animal contact, exposure to mechanical forces, and physical interpersonal violence) using ICD codes. Deaths due to fractures were estimated as the proportion of in-hospital deaths due to the specified injury causes for which a fracture (nature of injury code) was more severe than the cause of injury code. YLDs and DALYs attributable to low bone mineral density by cause of injury were also determined according to previous GBD methods. FINDINGS: In 2020, 8·32 million (95% UI 5·58-10·84) YLDs, 17·2 million (14·1-20·2) DALYs, and 477 000 (411 000-536 000) deaths were attributable to low bone mineral density globally in individuals aged 40 years and older. Between 1990 and 2020, global YLDs, DALYs, and deaths attributable to low bone mineral density increased by 91·8% (88·5-95·1), 89·8% (81·5-99·0), and 127·1% (108·5-144·5), respectively. Over this period, the age-standardised global rates of YLDs, DALYs, and deaths attributable to low bone mineral density showed modest decreases. In 2020, falls accounted for 76·2% (95% UI 74·2-78·3) of YLDs, 65·2% (62·9-67·6) of DALYs, and 71·0% (67·4-72·8) of deaths attributable to low bone mineral density, and road injuries largely accounted for the remaining amount: 12·4% (11·1-13·6) of YLDs, 24·6% (22·5-27·1) of DALYs, and 23·1% (21·6-26·2) of deaths. As a proportion of all fall-related burden, low bone mineral density accounted for 26·6% (23·2-28·7) of YLDs, 25·6% (22·1-27·4) of DALYs, and 40·6% (35·4-44·0) of deaths in 2020. Of all road injury-related burden, 12·6% (10·8-13·5) of YLDs, 6·3% (5·4-6·9) of DALYs, and 8·9% (7·6-9·6) of deaths were attributable to low bone mineral density. In men, road injuries accounted for the largest proportion of DALYs attributable to low bone mineral density in those aged 40-59 years and the largest proportion of deaths in those aged 40-64 years. In women, road injuries were the leading cause of DALYs attributable to low bone mineral density in those aged 40-44 years and the leading cause of deaths attributable to low bone mineral density in those aged 40-54 years. In older age groups among both men and women, falls were the leading cause of the burden attributable to low bone mineral density. INTERPRETATION: Low bone mineral density is a crucial modifiable risk factor for fractures, which are an important cause of morbidity and mortality particularly in ageing populations. This analysis highlights low bone mineral density as a cause of health loss not just from falls, but also from road injuries.

The burden of diseases, injuries, and risk factors by voivodship in Poland, 1990–2023: a systematic analysis for the Global Burden of Disease Study 2023

Systematic analysis reveals disease and injury patterns across Poland, highlighting persistent subnational health inequalities between administrative regions.

A burden of proof study of the effects of exposure to high fasting plasma glucose on the risk of seven types of cancer

Systematic review and meta-analysis reveal moderate links between high fasting plasma glucose and breast, pancreatic, and colorectal cancer risk, suggesting needed interventions.

Global, regional, and national health-care inefficiency and associated factors in 201 countries, 1995–2022: a stochastic frontier meta-analysis for the Global Burden of Disease Study 2023

BACKGROUND: All governments face pressure to maximise the impact of their health budget. We aimed to measure health spending inefficiency for 201 countries from 1995 to 2022, estimate the cost of one additional year of healthy life, and assess contextual factors associated with health spending inefficiency. METHODS: We extracted data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2023 and the Financing Global Health 2024 project to estimate health spending inefficiency using a non-linear stochastic frontier meta-analysis model designed to assess health-adjusted life expectancy (HALE). This model produced a frontier that represents the best possible HALE for a given level of health spending. Inefficiency scores were measured as the distance between a country's HALE and the frontier at that country's level of spending. We used the slope of the frontier to estimate the cost of one additional year of healthy life, and we regressed inefficiency scores on contextual factors and policy variables to measure their association with health spending inefficiency. FINDINGS: The relationship between health spending and HALE was positive for all levels of spending, although health spending inefficiency existed in most countries. Globally, health spending inefficiency decreased from 1995 to 2019, increased considerably in 2020 and 2021 due to the COVID-19 pandemic, and recovered substantially in 2022. We found decreasing returns to additional health spending, with the cost of one additional health-adjusted life-year varying from US$92 (95% uncertainty interval 43-239) per capita for a country spending $100 per capita to $11 213 (8031-57 754) per capita for a country spending $5000 per capita. More efficient spending was associated with better governance, having a higher percentage of health expenditure from the government, infrastructure that facilitates access to and delivery of health care, and higher uptake of preventive care measures. INTERPRETATION: Expanding government-provided health-care coverage would decrease the inefficiency of the health-care system. Countries should also focus on strengthening democracy, building infrastructure, and increasing the use of, and access to, preventive care.

Examining the overlap in lymphatic filariasis prevalence and malaria insecticide-treated net access-use in endemic Africa

Eradication and elimination strategies for lymphatic filariasis (LF) primarily rely on multiple rounds of annual mass drug administration (MDA), but also may benefit from vector control interventions conducted by malaria vector control programs. We aim to examine the overlap in LF prevalence and malaria vector control to identify potential gaps in program coverage. We used previously published geospatial estimates of LF prevalence from the Institute for Health Metrics and Evaluation, as well as publicly available insecticide-treated net (ITN) access (proportion of the total population with access to ITNs) and use (proportion of the total population that slept under an ITN) estimates among the total population and malaria Plasmodium falciparum parasite rates (PfPR) from the Malaria Atlas Project (MAP). We aggregated the 5x5 km2 estimates of LF prevalence estimates and ITN estimates to the implementation unit (IU) level using fractional aggregation, for 33 LF and malaria-endemic locations in Africa, and then overlaid the IU-level aggregates. In this analysis, ITN coverage was low in areas where LF is common, with 51.7% (90/174) of high-LF-prevalence-IUs having both access and use estimates under 40%. Most (67.8%; 61/90) of these low-ITN-coverage, high-LF-prevalence locations were also categorized as high- or highest-prevalence for malaria by PfPR, suggesting suboptimal ITN coverage even in some malaria-co-endemic locations. Even in IUs with high LF prevalence but low malaria prevalence, almost half (48.2%; 39/81) had high levels of access to ITNs. When accounting for population, however, gaps in ITN access in such areas were evident: more individuals lived in high-LF, low-malaria IUs with low ITN access (8.68 million) than lived in high-LF, low-malaria IUs with high ITN access (6.76 million). These results suggest that relying on current malaria vector control programs alone may not provide sufficient ITN coverage for high LF prevalence areas. Opportunities for coordinated vector control programs in places where LF and malaria prevalence are high but ITN coverage is low - or additional ITN distribution in high-LF, low-malaria locations - should be explored to help achieve elimination goals.