None of the key elements of IVM  was reported at the time of the study as being optimally implemented in MVC in Uganda. For instance, evidence-based decision making was not being commonly used at the programmatic level to select vector control interventions, or in the more general formulation of malaria control policy. Inter-sectoral collaboration and community participation were also perceived as being poor while there was a notable lack of monitoring and evaluation related to MVC. Furthermore, shortage and uncertainty of financial resources as well as a poor health system infrastructure were identified as major impediments to implementation of IVM. The results, however, indicated that the majority of the participants knew the importance of MVC and the need for using an IVM approach. Considering that many participants were from the Ministry of Health, and some even from the National Malaria Control Programme, the disconnect between policymakers' good knowledge of IVM and the lack of implementation of the approach pointed to the need for greater investment in implementation science research related to malaria interventions . The results also confirmed what has previously been reported about the lack of a clear IVM policy in Uganda .
Regarding the choice and integration of vector control interventions, the most effective methods were considered to be ITNs/LLNs and IRS. Larviciding and environmental management were regarded as important interventions although not routinely implemented. An area of great concern for participants was the use of DDT for IRS, as evidenced by responses as to which vector control method participants thought had the biggest potential for harm, if not managed properly. DDT has been associated with serious consequences to human health if used indiscriminately for pest control , or even when only limited to IRS for malaria vector control . Furthermore, contamination of crops with DDT can have negative economic consequences as it may lead to a rejection of food and other products intended for the export market . Insecticides such as DDT therefore require careful monitoring in order to mitigate unintended negative effects, and also to forestall development of insecticide resistance in malaria vector populations .
While the concern about DDT was perhaps an indication of a general awareness in Uganda about the negative health and environmental impacts of chemical pesticides, it warrants further research as it could also have been simply due to political controversy surrounding the use of DDT [24, 35]. Conducting prior environmental assessments for vector control interventions and putting in place a monitoring and evaluation system to aid in detection of resistance and informed decision making can have great cost-saving benefits in the long term, as well as ensuring the longevity of public health insecticides currently in use .
When asked about the current level of research being done, half of participants felt it was inadequate. However, when it came to research being used to facilitate changes in policy when there was need to adapt current interventions to changing malaria vector or disease situations, participants indicated that such policy changes happened only rarely or sometimes. This slow translation of research into policy changes can result in waste of resources as has been observed in some southern African countries, where interventions that are no longer working effectively are still used .
Through responses from participants, it became clear that more needs to be done to monitor effectiveness of interventions. Generally, monitoring and evaluation are necessary in order to improve the efficiency and effectiveness of health interventions and their management, including those for malaria vector control [38, 39].
On inter-sectoral collaboration, a few participants commented that there was a lack of shared goals and resources among the various sectors, most notably the health, environment and agricultural sectors. Their recommendation was that the health sector or a special task force should be assigned the role of coordinating IVM between these sectors. Appointing a multidisciplinary team to aid in horizontal communication between different sectors has been shown to be effective in promoting and facilitating inter-sectoral cooperation in public health . It has also been previously recommended for implementation of IVM .
Traditionally, legislators have viewed sectors as separate areas, compartmentalizing them and leaving only small areas for cooperation. This has only recently begun to change, with focus moving toward integration . Legislation might thus be an effective way of encouraging cooperation among sectors, while at the same time spelling out the mechanisms and challenges on how it is achieved .
Nevertheless, it is important that a sector does not become overly preoccupied with collaborative efforts to a point of being ineffective in performing its core functions. Continual improvement of collaboration through informal networking and formalised and structured planning is seen as one of the best methods of enhancing institutional organisation . One participant emphasized that different sectors should not only share practices, but work to improve communication between them to strengthen cooperation. The agricultural sector as well as the Ministry of Works, which is responsible for sanitation in Uganda, were mentioned specifically by participants as having poor practices that promote mosquito breeding . This is a good example of where not only shared knowledge but also shared resources can promote IVM, especially since the creation of irrigation and sanitation systems falls outside the jurisdiction of the Ministry of Health.
On the basis of the interview results and available literature, Uganda should form multi-sectoral coordinating committees to oversee and facilitate cooperation between the various sectors at the national and district levels [16, 44]. Decentralized organizing committees have generally been shown to achieve their designated goals efficiently because of a better focus on local needs of the communities within which they operate . The use of decision analysis support tools can also bring together stakeholders with competing health, environmental and economic objectives to evaluate various options and their trade-offs (22).
Although legislation was placed last when participants were asked to rank the various key elements of IVM, many participants viewed it as a powerful factor for effective implementation of the approach. All participants agreed that legislation was necessary and needed to be improved upon in Uganda. However, using legislation to enforce community participation should perhaps only be considered as a last option, with emphasis rather being placed on educating communities to more willingly improve participation . Generally legislation can play a useful role in guiding the implementation of all the key elements of IVM .
As regards MVC-related capacity building needs, the study results corroborated previous observations that Uganda had the necessary entomological expertise to combat malaria and other vector-borne diseases . Unfortunately, such expertise on its own would not be sufficient to overcome the challenges of IVM implementation unless facilitated by well defined career pathways for vector specialists and an appropriate vector control infrastructure. Generally, the following four types of capacities are needed in a systems-based approach to health research and development [49, 50]: human capacity, i.e. individual skills and creativity; physical capacity, i.e. laboratories and equipment; organizational capacity, including management, strategies and decision-making capabilities; and social and governmental capacity, i.e. the requisite financial, social and political support for research. Addressing deficiencies in all the four areas of capacity would be necessary for the successful implementation of MVC for malaria control in Uganda. It is worth noting that the lack of funds as cited in the present study reinforces the need for strengthening IVM's key element on inter-sectoral collaboration in order to share not only technical expertise but also the financial cost of sustaining MVC.
While the above factors mainly relate to institutional capacity building, it would be equally important to keep malaria knowledge among communities in Uganda at a high level. The problem of illiteracy, particularly in rural settings, was mentioned by participants as creating high risk population groups that are affected the most by malaria. Studies elsewhere have shown that as malaria in a community decreases, so does the awareness of the dangers of the disease, which could in turn lead to an increase in the incidence of cases due to failure to observe the necessary measures .
Regarding monitoring and evaluation, it is recommended that Uganda should train teams at the village level to undertake basic monitoring of MVC among communities, as was done in the past as part of the country's efforts to reduce HIV/AIDS . Timely reporting of information has been found in neighbouring Tanzania as aiding malaria control programme managers in the prompt identification of problems that arise during implementation of interventions . Such village-level feedback could be crucial in helping programme managers in Uganda to assess whether or not particular IVM initiatives are successful.
Finally, it was obvious from the results that IVM policy development in Uganda would have to take into consideration the prevailing political and socio-economic context to ensure implementation. Both poverty and political agenda were viewed as constituting critical barriers to implementation of currently available vector control methods. Interest in understanding the political and social dimensions of policy making in sectors which traditionally relied on having only compelling scientific evidence in order to institute any policy changes has been growing. The trend has in recent years been discussed in detail for policy processes in general , and in development of healthy public policy in particular .