Malaria accounts for a large burden of disease in developing countries especially in sub-Saharan
Africa (SSA) and understanding the most cost effective methods for malaria control is both an
economic and a public health priority. According to the World Health Organization, an estimated
190-330 million episodes of malaria occur each year globally and SSA accounts for about 90%
of the global burden of malaria (World Health Organization, 2011). Some of the groups most
vulnerable to malaria infection are children aged 5 years and below as well as expectant mothers.
The 2011 World Health Statistics report shows that malaria accounts for 18% of death among
children aged less than 5 years in SSA—compared to the global average of 9%. As such,
reversing the incidence of malaria and other major diseases is one of the Millennium
Development Goals (MDGs) adopted by the United Nations in 2000. In order to meet the MDG
targets, international funding for Malaria prevention and treatment has increased tremendously.
Through programs such as the Global Fund for AIDS, Malaria and Tuberculosis and the Roll
Back Malaria Global Action Plan, at least US$ 1.1 billion was earmarked by international
agencies for malaria interventions in SSA in 2008—up from US$ 250 million in 2004 (United
Nations, 2009). Over time, countries in SSA have adopted a number of interventions in order to
prevent the spread of malaria parasites—ranging from vector control to prevention of malaria
during pregnancy.
Malaria is endemic in Uganda. At least 95% of the country is infested with mosquitoes that carry
the pathogens that cause malaria and at any given time at least 50% of Ugandans who report
illness indicate suffering from Malaria (Ssewanyana et al., 2004). The Ministry of Health (MoH)
in Uganda estimates that in a given year, at least 12.3 million cases of malaria are registered
across the country (Ministry of Health, 2010). The disease is most prevalent among children
aged 5 years and below and among pregnant women. Initially, the Government of Uganda
(GoU)’s efforts to control malaria focused on the biologically vulnerable—in particular early
detection and treatment of the disease among children as well as the provision intermittent
treatment of malaria among pregnant women. Indeed, the above two strategies were the main
methods used to prevent the spread of the disease in the 1990s (Ministry of Health, 1999).
Starting in 2000, the GoU intensified efforts to provide Insecticide Treated Nets (ITNs) as
primary means of preventing malaria during the implementation of Health Sector Strategic Plan
2
(HSSP I, 2000-2005). Overtime, the proportion of Ugandan households with at least one net
increased from 13% in 2000 to 59 % by 2009 (Uganda Bureau of Statistics and IFC Macro,
2010). Furthermore, by 2009, at least 46% of households had at least one Long Lasting
Insecticide Treated Net (LLIN).1
With support from the Global Fund for HIV/AIDS, Malaria,
and Tuberculosis (GFMAT) under Round 7, the GoU intends to achieve universal coverage of
LLINs by the end of 2013. At the same time, partly because malaria remained endemic even with
the expansion in malaria control programmes, the government reintroduced Indoor Residual
Spraying (IRS) in 2006. However, household access to IRS remains fairly limited across Uganda
due to inadequate funding.
On the other hand, despite spending substantial resources on different modes of malaria
prevention, there is limited information of the cost effectiveness of various interventions in
reducing the burden due to malaria in Uganda. Previous analysis e.g. Kolaczinski et al., (2010)
have focused on examining the cost effectiveness of different modes of delivering LLINs—either
through targeted public health campaigns or through routine antenatal care services. To the best
of our knowledge there are no studies evaluating the cost effectiveness of different malaria
control programmes. The present study attempts to fill the policy vacuum by analyzing the cost
effectiveness of the current two predominant methods of malaria prevention in Uganda—the
provision of Long Lasting Insecticide Treated Nets (LLINs) and IRS. We assess the cost
effectiveness in terms of the cost of reducing a given number of malaria cases or deaths—
following the framework used in earlier studies such as Goodman et al., (2001) for Kwazulu
Natal in South Africa. In particular, we examine the cost effectiveness of delivering either LLINs
or IRS for control of malaria among children aged 5 years and below in two districts of Uganda.
The focus on this particular demographic group is because that is where the incidence of malaria
is highest. Also, most of Uganda’s malaria control efforts have targeted this particular age group
in addition to pregnant women. Finally, the justification for focusing on infants is also partly
guided the availability of accurate data on malaria incidence. Most recent malaria surveys in
developing countries (like the one used in this study) only conduct laboratory tests for malaria
for children aged 5 years and below. Consequently, for this age group, we have representative

1
Long Lasting Insecticide Treated Nets (LLINs) provide insecticide protection for about 5 years and do not require
re-treatment like the previous traditional Insecticide Treated Nets (ITNs).
3
information based on laboratory diagnosis of malaria rather self assessed symptoms of malaria or
rapid diagnostic blood tests (RDT).2

The rest of the study is organized as follows. In the next section, we describe the context as well
as the policy frameworks that guide malaria control programmes in Uganda. Section three
describes the data and methods used in the analysis. The results for cost effectiveness analysis
are presented in section four while section five provides the conclusions and implications of the
study