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                               MINISTRY OF HEALTH

                                     Beta version: 1.9
                                      7th March 2003


In most parts of Uganda temperature and rainfall are sufficient to allow a stable,
perennial malaria transmission at high levels with relatively little seasonal variability.
Only in the high altitude areas in the Southwest and East malaria transmission is
generally low with more pronounced seasonality and the occurrence of epidemics (e.g.
1992, 1994, 1997/98 and 2000/2001).

Based on this epidemiology malaria significantly contributes to the burden of disease as
well as economic losses. According to the 2001 „Roll Back Malaria“ (RBM) base line
assessment in four districts between 39% and 44% of recorded outpatient visits were
due to malaria. It is estimated that between 70,000 and 100,000 people die from malaria
each year, the great majority of them children under five years. A considerable number
of studies have consistently shown that the great majority of malaria episodes (50-80%)
are handled in the private sector either through self-medication or consultation of drug
shops or private sector facilities. However, management of malaria fevers is still poor.
Only 28% of those patients seen at a health facility were managed correctly and only 7%
of caretakers of children under 5 years sought treatment within 24 hours (RBM base
line). The direct and indirect cost of malaria are high and it has been estimated by WHO
that poor households spend up to 25% of their monthly income on malaria.

The Uganda National Health Policy as well as the Health Sector Strategic Plan (HSSP)
acknowledges the importance of malaria prevention and control as a crucial element not
only for improvements in the health status of the population but also for poverty
alleviation. Consequently, malaria is given a high priority within the minimal health care
package formulated in the HSSP.

The key strategies and interventions for the prevention and control of malaria are laid out
in the Uganda Malaria Control Policy (1998) and the more recent Uganda Malaria
Control Strategic Plan (2001/2-2004/5). Both documents highlight the use of insecticide
treated materials (mosquito nets and curtains) as the most critical and cost-effective
intervention in the area of transmission prevention and vector control. The Strategic Plan
further outlines the rough roles of the various players (public sector, civil society and
private sector) and describes the mechanism of coordination (Interagency Coordination
Committee on Malaria and its Vector Control/ITN Working Group). What is lacking in
these documents, however, is a clear presentation of a detailed implementation strategy
for the wide utilization of ITNs.

In the context of the ICCM Vector Control/ITN Working Group all key partners have
worked together in a participatory process to develop this document which describes
how Uganda will rapidly go to scale with insecticide treated nets.


Use of mosquito nets in general and insecticide treated nets (ITN) in particular is
relatively new in Ugandan communities. Since the introduction of ITN in the country in
the early 1990s, the promotion of their use has been mainly by NGOs in the form of
limited projects covering small populations. Surveys done in 1995 and 1996 by AMREF
and GTZ indicated that less than 1% of the population used mosquito nets at that time.

Since then significant progress has been made in the promotion of ITNs and the
establishment of a commercial market for nets as well as insecticides. In 1998 the
Ministry of Health has included ITNs in the National Malaria Policy as one of the key
strategies for malaria prevention. In 1999 import tariffs as well as value added tax (VAT)
has been waived for mosquito nets and netting material and in 2002 the Uganda Bureau
of Standards has adopted the WHO recommended quality standards for mosquito nets
which are expected to be applied to all imported mosquito nets after January 1st 2003.

This creation of a favourable environment coupled with increasing awareness and
demand from the population has dramatically improved the supply side for ITNs in the
country. In 2002 at least 4 commercial net and/or insecticide distributors and one social
marketing project are active which are selling either high quality mosquito nets alone,
nets co-packed with a single dose of insecticide or factory pre-treated long-lasting ITN
through expanding distribution networks. This is complemented by some ITN distribution
through District Health Services which had purchased these previously through funds
from the District Health Services Project and by sales of untreated nets of lesser quality
through hawkers and small shops. The total annual sales of mosquito nets in Uganda
has increased from an estimated 40,000 nets in 1999 to about 100,000 in 2000 and
250,000 in 2001. About one half of these are channelled through 20 NGOs active in the
distribution of ITN, the other half sold in the commercial market. The price of an ITN has
decreased in recent years. A family sized net was sold for 6.6-10.3 US$ in 1998/99, it is
between 4.3 and 7.7 US$ in 2001/2002.

With increasing availability of nets and insecticide the ITN coverage and utilization in
Uganda has increased. Based on a number of data sources (e.g. UDHS 2000/2001,
RBM base-line, CMS survey, Netmark) the proportion of households with at least one
mosquito net in 2000/2001 can be assumed to vary between 15% -45% in urban centres
and 2-15% in rural areas with a country wide estimate of 12.8% (UDHS). However, the
proportion of these nets which are insecticide treated is still very low ranging between
2% and 20% and the overall coverage of children under five years of age with ITN does
not exceed 2-3% at national level (UDHS).

The major problems faced for going to scale with ITNs in Uganda therefore are:

      Still insufficient awareness of particularly the rural population of the existence of
       ITN and their potential benefit for health as well as economic burden to the
      Insufficient penetration of the commercial ITN distribution networks in the rural
       areas resulting in poor availability and visibility of the products (nets as well as
      Insufficient promotion and opportunities for net retreatment or treatment of
       previously untreated nets with insecticides through either “do-it-yourself” kits or
       net treatment services (commercial or otherwise).

For all three problems cost/affordability is not the only but a key issue. This is true for the
stocking of nets at rural shops and other outlets as well as for the ability to actually buy
nets or insecticide re-treatment by the affected population and any strategy to increase
the use of ITN in Uganda must take this into account.


Over 80% of people living in malaria-endemic areas of Uganda sleep under insecticide-
treated nets. The majority of these people purchase their ITNs from the unsubsidised
commercial market. However, vulnerable groups can obtain subsidised ITNs.

Prices are kept low in the commercial market in both urban and rural areas due to
economies of scale as well as competition among ITN suppliers and retailers.
Government helps by providing an enabling environment which includes generic
promotion of ITN products as well as a supportive fiscal and regulatory environment.

Government and NGOs provide a system of targeted subsidies that focus on vulnerable
groups. These comprise the biologically vulnerable (pregnant women, under-fives) and
the socio-economically vulnerable (e.g. the very poor, orphan-headed households,
displaced populations). Subsidies will be targeted and implemented in such a way that
the private sector is not undermined but rather supported, wherever possible.


Uganda is committed to the Abuja Declaration and, hence, is aiming to achieve the
following targets:

      To increase the proportion of children below 5 years using ITNs from 3% to 60%
       by the year 2005.
      To increase the proportion of pregnant women using ITNs from 0.5% to 60% by
       the year 2005.

In addition, Uganda has two additional targets related to household net coverage:

      To increase the proportion of household with one or more nets from 13% to 75%
       by the year 2005.
      To increase the proportion of households with one or more treated nets from 3%
       to 60% by 2005.


a. The Partnership Development Process

Collaboration is essential among a range of partners in order to increase access to ITNs,
create and sustain demand, achieve affordability and encourage proper use. The
Ministry of Health will take the lead in developing and guiding the partnership. This will
primarily be carried out through the Vector Control/ITN Working Group whose
recommendations will be discussed by the Interagency Coordinating Committee on
Malaria and decisions taken.

National policy guidelines will be presented by the Ministry of Health to partners and
complementary plans for scaling up ITN coverage agreed upon. The products to be
promoted should meet the required standards as gazetted in The Uganda Gazette, Vol.
XCV No.5, 25 January 2002, 31. US 307:2001, 28. US 308. Both geographical and
socio-economic market segmentation will be needed to ensure civil society’s efforts in
scaling up ITN coverage among the poor and vulnerable do not destabilise the nascent
private sector.

A successful and lasting partnership will be possible when it is recognised that while
different partners have different priorities, all need to be working towards the same goal
and vision.

b. Roles of the partners

Effective implementation of the proposed strategy will require strong partnership and
commitment from all partners to ensure that materials (nets and insecticides) are
available, affordable and demanded at the consumer level. For the partnership to be
sustained, the aims and roles of each partner must be clearly defined.

The partners can be categorised as:
    the public sector
    civil society
    the private sector

Their respective roles are given below:

Public sector (Ministry of Health)
    create an enabling environment for all partners
    mobilise resources (i.e. budgeting within the health budget and soliciting funds
        from elsewhere)
    promote generic demand through use of a variety of approaches and channels
    co-ordinate and chair the ICCM Vector Control/ITN Working Group and the
        involvement of partners in going to scale with ITN coverage
    provide technical support, supervision and guidelines, monitor vector resistance
        to insecticides and undertake operational research
    set standards and norms for nets and insecticides, and monitoring and regulating
        their quality
    provide of ITNs to vulnerable groups during emergency situations
    support systems for targeted subsidies to vulnerable groups, e.g. distribute ITN
        vouchers for under-fives and pregnant women through health facilities
    with partners, monitor and evaluate efforts to go to scale with ITN coverage

Public sector (Other Government Ministries)

The Vector Control/ITNs Working Group will liaise with other ministries, such as
Education and Sports; Agriculture, Animal Industry and Fisheries; Local Government;
and Trade and Industry, to identify the roles they can play. Following this, they will be
invited to participate in the development of implementation plans.

Development Partners:
    Resource mobilisation.
    Provide strategic and technical support for ITNs programme when and where
    Advocacy for ITNs.
    Act as catalysts for partnerships.
    Monitoring and evaluation of ITNs programmes.

Private sector (Mosquito net and insecticide manufacturers and distributors):
     create awareness and demand for branded net and insecticide products
     improve product based on consumer research
     carry out monitoring of the commercial market
     supply ITNs and insecticide for net retreatment countrywide through an
        expanding distribution network.
     supply ITNs for a system of targeted subsidies (e.g. vouchers)
     support ITN use through employer-based schemes
     support for retailers to stock and promote ITNs
     with partners, monitor and evaluate efforts to go to scale with ITN coverage

Private sector (Those not dealing with mosquito nets and insecticides):
 Support mobilisation, provide resources or ITNs particularly for targeted vulnerable
    groups (pregnant women, under fives) and during emergencies (internally displaced
    people living in camps).
 Initiate employer-based ITNs programmes and net treatment services for their staff

Civil society
     social market subsidised ITNs and treatment kits
     coordinate and manage a voucher scheme for subsidised ITNs targeted at
        vulnerable groups
     distribute subsidised ITNs to the very poor through existing NGO, FBO and CBO
     provide ITNs to vulnerable groups during emergency situations
     with partners, monitor and evaluate efforts to go to scale with ITN coverage

Inter Agency Coordinating Committee on Malaria (ICCM):
     Endorse, advocate and ensure the implementation of the ITNs Policy and
     Mobilization of resources for the implementation of the ITNs Policy and Strategy
        from both within and outside Uganda.
     Coordinate partnerships and all inputs and resources available for the
        implementation of the ITNs Policy and Strategy both from within and outside the
     Provision of technical and programmatic advice on ITNs programme
        implementation issues as and when they arise
     Monitoring and evaluation of the ITNs programme activities in order to identify
        gaps and strengths

      Assist in consolidating the identified strengths and removing or reducing the

c. Development of a communication strategy and other operational guidelines:

An integrated Malaria Control Communication Strategy will be developed to include
ITNs. Appropriate operational guidelines to help in ITNs programme implementation will
also be developed. These will be disseminated to all the ITNs programme implementers.

d. Use of subsidies to increase access of vulnerable groups

Given the situation that cost is currently one of the most important obstacles to rapid
going to scale, subsidies will be used to make ITNs and insecticide for net retreatment
more affordable. In order not to interfere unnecessarily with the growing commercial
market for ITNs, subsidies for ITN will be targeted at the very poor, and the biologically
vulnerable (pregnant women and under-fives). In contrast, retreatment kits (single net
insecticide dose) will be subsidised for the general population in order to markedly
improve net retreatment rates.

Improving access to ITNs for the very poor
Existing NGO, FBO and CBO initiatives will be supported to provide subsidised nets (50-
95% of the cost) to the very poor. Only initiatives that target the very poor will be
supported. Various mechanisms will be used including cost-reduction for school children,
cost-sharing through health insurance schemes, community development initiatives etc.

Improving access to ITNs for pregnant women and under-fives
A voucher system that entitles money off ITN purchases for pregnant women and
children under-five years visiting antenatal and child health clinics will be used to
improve access to ITNs of these groups. An appropriate system for voucher distribution
and redemption shall be put in place.

Improving access to net retreatment
In order to increase the low level of net retreatment, retreatment kits will be subsidised
across all sectors. In the public sector, limited distribution of kits will be carried out using
existing community mechanisms (e.g. Community-Owned Resource Persons, CORP).
NGOs will support the distribution of kits to retail outlets in rural areas through social
marketing. In addition, NGOs will provide limited numbers of subsidised kits through
community-based projects. The private sector will distribute subsidised kits to retail
outlets in rural and urban areas.

e. Outputs and key activities by sector

The Uganda ITN strategy has the following outputs:
   1. Widespread demand created for ITNs and retreatment

   2. ITNs available in rural and urban retail outlets

   3. Affordable net retreatment is available to rural and urban net owners

   4. The very poor have access to affordable ITNs

              5. Pregnant women and under-fives have access to subsidised ITNs

           6. ITNs used for emergency situations
       Key activities by sector that will contribute to achieving these outputs are given in the
       table below.

       Major planned activities by output and sector
Outputs         Public sector activities         Civil Society Activities          Private sector activities
                Generic promotion and            Branded, generic and              Branded promotion and
                advocacy                         multibrand promotion              advocacy
                    Creation of an enabling        Branded, generic and             Branded ITN campaigns
                     environment for all             multi-branded ITN                 using a variety of media
                     partners/stakeholders           campaigns using a                Branded retreatment
                    Development and                 variety of media                  campaigns using similar     Under-fives
                     dissemination of IEC           Multibrand and/or                 channels                    Pregnant
                     materials                       generic retreatment                                           women
created for
ITNs and            Organize/conduct                campaigns using similar                                       General
                     advocacy meetings at            channels                                                      population
                     national, district and
                     sub-district levels
                    Community sensitisation
                     through local
                     government structures
                Co-ordination and monitoring     ITNs provided to retail           ITNs provided to retail
                of private sector and civil      outlets in rural and urban        outlets in rural and urban
                society activities               areas through social              areas
                    Conduct regular             marketing                             Ensure a regular supply
                     planning meetings with          Market priming by                 of ITNs
2. ITNs
                     the commercial sector            expanding the ITN                Expansion of ITN
available in
                     and civil society                distribution network and          distribution network,      General
rural and
                    Advocate for partners to         putting in place                  including strengthening    population
urban retail
                     expand activities to             incentives that                   delivery systems to
                     underserved areas                encourage small                   service rural and urban
                                                      retailers, particularly in        markets
                                                      rural areas, to stock            Encourage retailers to
                                                      ITNs                              stock ITNs through
                                                                                        incentive schemes
                Limited distribution of          Subsidised retreatment kits       Subsidised retreatment kits
                subsidised retreatment kits      provided to rural and urban       provided to retail outlets in
                through existing public sector   communities                       rural and urban areas
                mechanisms                          Social marketing of               Ensure a regular supply
3.                  Improve access to               subsidised retreatment             of retreatment kits
Affordable           retreatment kits using          kits to distributors,             Expansion of
net                  parish and village              wholesalers, retailers             retreatment kit
retreatment          development                    Community-based                    distribution network,      General
is available         committees, agricultural        organizations purchase             including strengthening    population
to rural and         extension workers etc           and distribute                     delivery systems to
urban net           Establish community-            subsidised retreatment             service rural and urban
owners               based subsidised net            kits                               markets
                     retreatment services                                          
                     (e.g. at schools, meeting
                     points), where
                Government mechanisms            Subsidised ITNs distributed       Subsidised ITNs distributed
4. The very
                used to identify and reach       to the very poor                  to the very poor
poor have
                the very poor                        NGOs, FBOs and CBOs              Donations
access to                                                                                                          Very poor
                    Advocate for districts to        purchase and distribute          Kick-start community
                     use Poverty Alleviation          ITNs at highly                    ITNs outlets by
                     Funds for ITNs                   subsidized prices using           providing a level of

Outputs       Public sector activities            Civil Society Activities          Private sector activities
                   Liase with appropriate            a variety of mechanisms           credit
                    ministries to identify very
                    poor communities
                    unable to afford ITNs
              Assist with the distribution of     Co-ordination, management         Participation of private sector
              vouchers through health             and social marketing of a         in voucher programme
              facilities                          voucher system                        Vouchers distributed by
5. Pregnant        Sensitisation and                 Pilot voucher                     private health facilities
women and           training of health                 programme                         to beneficiaries
under-fives         workers to distribute             Design and implement a           ITNs supplied by             Pregnant
have                vouchers and                       national voucher                  distributors                 women
access to           communicate benefits of            programme following              Retailers to stock ITNs,     Under-fives
subsidised          ITN use                            piloting                          redeem vouchers and
ITNs                                                  PNFPs to distribute               sell ITNs
                                                       vouchers and
                                                       communicate benefits of
                                                       ITN use
              Provision of ITNs during            Distribution of ITNs to highly    Distribution of ITNs to highly
              emergencies                         vulnerable, displaced and         vulnerable, displaced and
                 Establish a stockpile of        refugee populations               refugee population
6. ITNs           ITNs and treatment kits             NGOs involved in relief          Donations                    Internally
used for          (or fund) to use in an               activities distribute ITNs       Quick delivery of ITNs       displaced
emergency         emergency                            and retreatment kits                                           populations,
situations       Collaboration with civil                                                                            refugees
                  society and/or private
                  sector to ensure a
                  prompt response

      a.            Monitoring and evaluation

      The Ministry of Health will co-ordinate the monitoring and evaluation of the National ITN
      Strategy making sure that all possible sources of malaria relevant information are being
      used such as Demographic and Health Surveys, Home Based Management of Fever Strategy
      and IMCI monitoring, data from malaria surveillance activities and other surveys by
      various partners. Implementation progress will be reviewed on a quarterly basis using
      the Vector Control/ITN Working Group of the Interagency Coordination Committee on
      Malaria as the forum. Through this mechanism the sharing of information between
      partners will be fostered.

      The core indicators used to assess progress towards the achievement of the targets of
      this strategy are in accordance with those from the Uganda Malaria Control Strategic
      Plan and the Health Sector Strategic Plan.

Target                     Indicator                                                  Measuring tool and
1. Increase of the            Proportion of children under 5 years who have      National estimate from UDHS
proportion of children         slept under an ITN the previous night              (2005); annual data from HBMF
under five using ITN           increases from 3% to 60% by 2005                   and RBM sentinel sites;
                                                                                  surveys by other partners
2. Increase of the            Proportion of currently pregnant women who         National estimate from UDHS
proportion of pregnant         have slept under an ITN the previous night         (2005); annual data from HBMF
women using ITN                increases from 0.5% to 60% by 2005.                and RBM sentinel sites;
                                                                                  surveys by other partners
3. Increase in the            Proportion of sampled households with one or       National estimate from UDHS
proportion of                  more nets increases from 12.8% to 75% by           (2005); annual data from HBMF
households with                2005                                               and RBM sentinel sites;
mosquito nets                                                                     surveys by other partners
4. Increase in the            Proportion of sampled households with one or       National estimate from UDHS
proportion of                  more nets which have either been treated with      (2005); annual data from HBMF
households with ITNs           insecticide within last 6 months or are factory    and RBM sentinel sites;
                               pre-treated using a long-lasting technology        surveys by other partners
                               increases from 3.2% to 60% by 2005

       The following key indicators will be used for the monitoring of the achievement of outputs
       described in section 5d) of this document.

Output                     Indicator                                                  Measuring tool and
1. Widespread demand          Proportion of population who is aware of           National estimate from UDHS
created for ITNs and           insecticide treated nets and their need for        (2005) ?; annual data from
retreatment                    retreatment increases to 75%                       various household surveys.
                              Estimated total annual sales of ITNs through       Annual sales reports from
                               major distributors increases from previous         partners
2. ITNs available in          Number of outlets for ITN disaggregated            Bi-annual reports from partners
rural and urban retail         by distributor and district increases from
outlets                        previous year
                              Number and duration of any stock outs of ITN       Bi-annual reports from partners
                               supply by major distributors reduces to nil
3. Affordable net             Number of outlets for insecticide for nets         Bi-annual reports from partners
retreatment is available       disaggregated by distributor and district
to rural and urban net         increases from previous year
owners                        Number of treatment units (kits or equivalent      Bi-annual reports from partners
                               liquid) sold/distributed without nets increases
                               from previous year
4. The very poor have         Number of nets distributed to the very poor        Annual NGO reports
access to affordable           disaggregated by district
5. Pregnant women and         Number of outlets (ANC and other health            Bi-annual reports from voucher
under-fives have               facilities) participating in the distribution of   system
access to subsidised           targeted subsidies
ITNs                          Number of ITN vouchers redeemed and nets           Bi-annual reports from voucher
                               issued                                             system
6. ITNs used for              Number of ITN distributed to highly                Annual NGO reports

Output                    Indicator                                          Measuring tool and
emergency situations          vulnerable, displaced and refugee population
                              by district
      b.           Timeline and milestones

      The implementation of the ITN strategy for going to scale is to run in parallel to the
      Uganda Malaria Control Strategic Plan – 2001/2-2004/5. However, for some outputs (1-3
      and 5) key activities need to be accomplished at certain times for the programme to be

Output                             Milestone                                       To be achieved by
1. Widespread demand created       Initial national and district sensitization and By end of Year 1
for ITNs and retreatment           advocacy for ITNs carried out

                                   Generic promotion campaign started            By end of Year 1
2. ITNs available in rural and     Expansion of commercial distribution networks
urban retail outlets               for ITN to 40% of districts                   By end of Year 1

                                   Expansion of commercial distribution networks By end of Year 2
                                   for ITN to 80% of districts
3. Affordable net retreatment is   Funds for general subsidies of insecticide for By end of Year 1
available to rural and urban net   retreatment available from GFATM
5. Pregnant women and under-       Experience from pilot scheme for targeted By end of Year 1
fives have access to subsidised    subsidies available
                                   Funds for targeted subsidies for ITN on
                                   national level available from GFATM     By end of Year 1

                                   National voucher system for targeted subsidies By end of Year 2
                                   ready for implementation


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