POLICY AND STRATEGY FOR INSECTICIDE TREATED NETS. Malaria Control Programme Ministry of Health Uganda

Transcription

1 POLICY AND STRATEGY FOR INSECTICIDE TREATED NETS Malaria Control Programme Ministry of Health Uganda March 2003

2 Foreword Insecticide-treated mosquito nets (ITNs) are a highly cost-effective malaria control intervention and a key component of the Ministry of Health s Malaria Control Strategic Plan Access to, coverage and use of ITNs, particularly among pregnant women and under-five year olds, are currently at unacceptably low levels and needs to increase significantly in the coming years. To do this, we need to address the dual challenge of increasing access to ITNs among vulnerable groups while at the same time supporting the development of the growing commercial market for ITNs. This document gives clear direction on how this challenge can be met. The ITN policy and strategy were developed by the Vector Control/ITN Subcommittee of the Inter-agency Co-ordinating Committee for Malaria. Subcommittee members included representation from Ministry of Health, the Malaria Consortium, WHO, UNICEF, USAID, Commercial Marketing Strategies, AMREF and the private sector. I would like to acknowledge their endeavours in producing this document. Professor Francis Omaswa Director-General, Ministry of Health NB. This document comprises two separate documents produced by the Republic of Uganda s Ministry of Health on Insecticide Treated Mosquito Nets. The Insecticide-Treated Mosquito Nets Policy includes two annexes: Specifications of Polyester Mosquito Nets and Netting Materials and Insecticides for Net Treatment and Guidelines for Managing ITN Donations. This is followed by Insecticide-Treated Mosquito Net Strategy. These two documents together form the Ministry of Health s policy and strategy on ITNs.

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5 The use of Insecticide-treated nets (ITNs) to prevent malaria is one of the key strategies of Uganda s Malaria Control Strategic Plan ( ). Moreover, increasing ITN coverage to 50% among under-fives is one of the key output indicators of the Uganda Health Sector Strategic Plan ( ). To support the rapid scaling up of ITN use in Uganda, the Ministry of Health has the following policy on ITNs: All mosquito nets imported into / manufactured in the country must conform with the Uganda Standard Specifications for Mosquito Nets (31.US 307:2001, The Uganda Gazette, Vol. XCV No.5, 25. January 2002) Refer to Annex 1, Table 1. All insecticides for mosquito net treatment imported into / manufactured in the country must conform with the Uganda Standard Specifications for Insecticides for Treatment of Mosquito Nets (28.US 308:2001, The Uganda Gazette, Vol. XCV No.5, 25. January 2002) Refer to Annex 1, Table 5. All mosquito nets that are sold or distributed in the public. Civil society and private sectors should be either pre-treated or packed with a net treatment kit. Mosquito nets should be retreated with appropriate insecticide on a regular basis. The Ministry of Health sees the future of insecticide-treated materials as long-lasting insecticide treated nets. To make ITNs more accessible to the most vulnerable groups, targeted subsidies will be employed. Approval from the National Vector Control/ITN Working Group as a sub-committee of the Interagency Coordination Committee on Malaria (ICCM) should be sought by all partners before the sale of subsidised ITNs to target groups occurs. Any system for targeting subsidies should be acceptable to, and agreed by, the partners assembled in the National Vector Control/ITN Working Group. Final decisions are to be made by ICCM. Distribution of free nets to the public should be minimised as much as possible by all partners except in special circumstances (e.g. emergencies). MCP will coordinate donations and will advise on appropriate mechanisms on their distribution in line with the ICCM approved guideline on donations. Uganda National Bureau of Standards (UNBS) will ensure the quality of nets brought into or manufactured in the country, while the National Drug Authority (NDA) will ensure the quality of insecticides brought into the country. 1

6 4' Table 1: Specification for Polyester Netting Materials Parameter Value Test method ( ISO) Fibre 100% polyester ISO 1833 Denier 75 ISO 2060 Filaments Multi-filament 36 Not available Mesh size Minimum 156 holes/inch 2 Not available Weight (g/m 2 ) Bursting strength 100 denier: 40 g/m 2 75 denier: 30g/m 2 ISO denier: minimum 405 Kpa. 75 denier: minimum 220 Kpa. ISO 2960 Shrinkage Threshold/range of < 5% ISO 6330 Dimensional stability Threshold/range of < 5% ISO5077 Fire safety 16 (CFR 1610 CS191 53) Type of netting Knitted ISO 8388 Colour fastness to: a) Light b) Washing 4 or better 4 or better ISO 6941:1984 Textile fabrics burning behaviour measurement of flame spread properties of vertically orientated specimens. Table 2: Specifications for Polyethylene Nets: Parameter Value Fibre 100% high-density polyethylene Denier >150 Filaments Mesh size 4 mm x 4 mm Weight (g/m 2 ) 50 Weave type Raschel Melting point About C Flashing point C Ignition point C 2

7 Table 3: Rectangular Net Dimensions Net Size Width(cm) Length (cm) Height(cm) Surface Area (m 2 ) X-small Small Medium Large X-Large N.B. Net sizes indicated here should be the minimum. Table 4: Conical Nets Dimensions Net Size Height ( cm) Circumference diameter (cm) Ring diameter (cm) Area (m 2 ) Single fitted conical Double fitted conical Extra double fitted N.B. Net sizes indicated here should be the minimum. Table 5: Recommended insecticide formulations and their target doses for the treatment of mosquito nets. Insecticide Formulation Concentration Trade name Dose ( mg/m 2 ) Alphacypermethrin SC 6 % Fendona Cyfluthrin EW 5 % Solfac Deltamethrin SC Tablet 1 % 25 % K- Othrine K-O Tab Etofenprox EW 10 % Vectron 200 Lambdacyhalothrin CS 2.5 % Icon SC - Suspension Concentrate EW - Emulsion in Water CS - Capsule Suspension Note: Notification shall be made to the public in case of any new insecticides that have been recommended by WHO and the relevant Ugandan authorities. Notification shall be made to the public in case of any insecticides that have been withdrawn by WHO and the relevant authorities. 3

8 4'!"#$ Distribution of ITNs remains a challenge in Uganda. Major problems are non-availability of ITNs in most parts of rural Uganda and the non-affordability by majority of the beneficiaries (women & children). The National ITN Policy and Strategy gives room for donations despite the focus on developing the commercial market for sustainability purposes. Generally, the National ITNs strategy aims at narrowing the gap between equity and sustainability. In order to streamline the operations of the ITNs programme and promote active participation of all stakeholders, operational guidelines have been developed in key activity areas i.e. distribution, IEC, M & E, re-treatment and use. This section defines ITN donations and explains the way how donated ITNs shall be handled at various levels. %&'#'('!# ITN donations shall mean and include ITNs provided at 100% subsidy to beneficiaries. ITN donations may include pre-treated nets, insecticides for treating nets, nets and insecticides bundled together, and, these should conform to the National Standards. #%)%#(!&$!#('!#* In order not to destabilize the commercial market, donated ITNs shall be handled according to the guidelines stated here below. 1. Donations should be targeted to people in emergency situations e.g. IDPs and refugee camps. 2. Donations should be provided with the knowledge of the public sector office at relevant levels for the purposes of monitoring and coordination. 3. Malaria Control Programme (MCP) should be informed of any such donations. 4. MCP through the ITNs Working Group shall keep ICCM informed of all major donations made to the country. Such donations made to Ministry of Health should be handled in the same way. 5. All donations should be accompanied with minimum data which should include:- - Name of sender or donor - Quantities of ITNs - Specifications of ITNs - Status of the ITNs (pretreated including date of treatment or bundled with date of manufacture of treatment kit) - Reasons for donating - Description of Recipient/beneficiary (the targeted area or community). 4

9 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. 5

10 4' 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 1 st 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 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 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 families. 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 insecticides). 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 6

11 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 socioeconomically 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: 7

12 4' To increase the proportion of children below 5 years using ITNs from 3% to 60% by the year To increase the proportion of pregnant women using ITNs from 0.5% to 60% by the year 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 To increase the proportion of households with one or more treated nets from 3% to 60% by /% (#% */'0%1%2!0)%#(!%** 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. 3!2%*!&(/% (#% * 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, development partners, civil society, the private sector. Their respective roles are given below: 8

13 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 ITN programmes when and where needed, advocacy for ITNs, act as catalysts for partnerships, monitoring and evaluation of ITN 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 members. Civil society social market subsidised ITNs and treatment kits, coordinate and manage a voucher scheme for subsidised ITNs targeted at vulnerable groups, 9

14 4' distribute subsidised ITNs to the very poor through existing NGO, FBO and CBO initiatives, 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 Strategy, 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 country, 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 gaps. %1%2!0)%#(!&!))"#'('!#( (%4#$!(/% 0% ('!#2 "'$%2'#%* 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. $ *%!&"3*'$'%*(!'# %*%%**34,"2#% 32%!"0* 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 underfive 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 10

15 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. % "(0"(*#$%4('1'('%*34*%(! 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 Output Public sector activities Civil society activities Private sector activities 1. Widespread demand created for ITNs and retreatment 2. ITNs available in rural and urban retail outlets Generic promotion and advocacy Creation of an enabling environment for all partners/stakeholders Development and dissemination of IEC materials Organize/conduct advocacy meetings at national, district and sub-district levels Community sensitisation through local government structures Co-ordination and monitoring of private sector and civil society activities Conduct regular planning meetings with the commercial sector and civil society Advocate for partners to expand activities to underserved areas Branded, generic and multibrand promotion Branded, generic and multi-branded ITN campaigns using a variety of media Multibrand and/or generic retreatment campaigns using similar channels ITNs provided to retail outlets in rural and urban areas through social marketing Market priming by expanding the ITN distribution network and putting in place incentives that encourage small retailers, particularly in rural areas, to stock ITNs Branded promotion and advocacy Branded ITN campaigns using a variety of media Branded retreatment campaigns using similar channels ITNs provided to retail outlets in rural and urban areas Ensure a regular supply of ITNs Expansion of ITN distribution network, including strengthening delivery systems to service rural and urban markets Encourage retailers to stock ITNs through incentive schemes Target groups Under-fives Pregnant women General population General population 11

16 4' Output Public sector activities Civil society activities Private sector activities 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 Limited distribution of subsidised retreatment kits through existing public sector mechanisms Improve access to retreatment kits using parish and village development committees, agricultural extension workers etc Establish communitybased subsidised net retreatment services (e.g. at schools, meeting points), where appropriate Government mechanisms used to identify and reach the very poor Advocate for districts to use Poverty Alleviation Funds for ITNs Liase with appropriate ministries to identify very poor communities unable to afford ITNs Assist with the distribution of vouchers through health facilities Sensitisation and training of health workers to distribute vouchers and communicate benefits of ITN use Provision of ITNs during emergencies Establish a stockpile of ITNs and treatment kits (or fund) to use in an emergency Collaboration with civil society and/or private sector to ensure a prompt response Subsidised retreatment kits provided to rural and urban communities Social marketing of subsidised retreatment kits to distributors, wholesalers, retailers Community-based organizations purchase and distribute subsidised retreatment kits Subsidised ITNs distributed to the very poor NGOs, FBOs and CBOs purchase and distribute ITNs at highly subsidized prices using a variety of mechanisms Co-ordination, management and social marketing of a voucher system Pilot voucher programme Design and implement a national voucher programme following piloting PNFPs to distribute vouchers and communicate benefits of ITN use Distribution of ITNs to highly vulnerable, displaced and refugee populations NGOs involved in relief activities distribute ITNs and retreatment kits Subsidised retreatment kits provided to retail outlets in rural and urban areas Ensure a regular supply of retreatment kits Expansion of retreatment kit distribution network, including strengthening delivery systems to service rural and urban markets Subsidised ITNs distributed to the very poor Donations Kick-start community ITNs outlets by providing a level of credit Participation of private sector in voucher programme Vouchers distributed by private health facilities to beneficiaries ITNs supplied by distributors Retailers to stock ITNs, redeem vouchers and sell ITNs Distribution of ITNs to highly vulnerable, displaced and refugee population Donations Quick delivery of ITNs Target groups General population Very poor Pregnant women Under-fives Internally displaced populations, refugees 12

17 5!#'(! '##$%12"('!# The Ministry of Health will co-ordinate the monitoring and evaluation of the National ITN Strategy making sure that all possible sources of malaria relevant information are being used such as Demographic and Health Surveys, Home Based Management of Fever Strategy and IMCI monitoring, data from malaria surveillance activities and other surveys by various partners. Implementation progress will be reviewed on a quarterly basis using the Vector Control/ITN Working Group of the Interagency Coordination Committee on Malaria as the forum. Through this mechanism the sharing of information between partners will be fostered. #$'(! * 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 1. Increase of the proportion of children under five using ITN 2. Increase of the proportion of pregnant women using ITN 3. Increase in the proportion of households with mosquito nets 4. Increase in the proportion of households with ITNs Indicator Proportion of children under 5 years who have slept under an ITN the previous night increases from 3% to 60% by 2005 Proportion of currently pregnant women who have slept under an ITN the previous night increases from 0.5% to 60% by Proportion of sampled households with one or more nets increases from 12.8% to 75% by 2005 Proportion of sampled households with one or more nets which have either been treated with insecticide within last 6 months or are factory pre-treated using a long-lasting technology increases from 3.2% to 60% by 2005 Measuring tool and frequency National estimate from UDHS (2005); annual data from HBMF and RBM sentinel sites; surveys by other partners National estimate from UDHS (2005); annual data from HBMF and RBM sentinel sites; surveys by other partners National estimate from UDHS (2005); annual data from HBMF and RBM sentinel sites; surveys by other partners National estimate from UDHS (2005); annual data from HBMF and RBM sentinel sites; surveys by other partners The following key indicators will be used for the monitoring of the achievement of outputs described in section 5d) of this document. Output 1. Widespread demand created for ITNs and retreatment Indicator Proportion of population who is aware of insecticide treated nets and their need for retreatment increases to 75% Estimated total annual sales of ITNs through major distributors increases from previous year Measuring tool and frequency National estimate from UDHS (2005)?; annual data from various household surveys. Annual sales reports from partners 13

18 4' Output 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 Indicator Number of outlets for ITN disaggregated by distributor and district increases from previous year Number and duration of any stock outs of ITN supply by major distributors reduces to nil Number of outlets for insecticide for nets disaggregated by distributor and district increases from previous year Number of treatment units (kits or equivalent liquid) sold/distributed without nets increases from previous year Number of nets distributed to the very poor disaggregated by district Number of outlets (ANC and other health facilities) participating in the distribution of targeted subsidies Number of ITN vouchers redeemed and nets issued Number of ITN distributed to highly vulnerable, displaced and refugee population by district Measuring tool and frequency Bi-annual reports from partners Bi-annual reports from partners Bi-annual reports from partners Bi-annual reports from partners Annual NGO reports Bi-annual reports from voucher system Bi-annual reports from voucher system Annual NGO reports 3 ')%2'#%#$)'2%*(!#%* 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 successful. Output Milestone To be achieved 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 Initial national and district sensitization and advocacy for ITNs carried out Generic promotion campaign started Expansion of commercial distribution networks for ITN to 40% of districts Expansion of commercial distribution networks for ITN to 80% of districts Funds for general subsidies of insecticide for retreatment available from GFATM By end of Year 1 By end of Year 1 By end of Year 1 By end of Year 2 By end of Year 1 14

19 Output Milestone To be achieved 4. Pregnant women and under-fives have access to subsidised ITNs Experience from pilot scheme for targeted subsidies available Funds for targeted subsidies for ITN on national level available from GFATM National voucher system for targeted subsidies ready for implementation By end of Year 1 By end of Year 1 By end of Year 2 15