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Malaria and the management of fevers is guided in Uganda by national strategy and MDG targets

The Ministry of Health has a Malaria Control Programme team which develops country ownership plans with its development partners. The Global Fund supports Uganda through ACT drugs and in the past with LLIN. Through the US Government's President's Malaria Initiative and in relation to maternal health, neonatal care and reducing opportunistic infections for those with HIV, LLIN are centrally purchased for distribution to lower income households and target populations. Uganda's 2010 plans note:

"According to Ministry of Health (MOH) records, malaria accounts for 25-40% of outpatient visits to health facilities and is responsible for nearly half of inpatient pediatric deaths. The most current information about national coverage of key malaria prevention and control measures in Uganda comes from the 2006 Demographic and Health Survey. According to this survey, 16% of households nationwide owned one or more insecticide-treated nets (ITNs) and 10% of pregnant women and children under five had slept under an ITN the night before the survey. The proportion of children under five treated with an anti malarial drug within 24 hours of onset of fever was 29%. Only 1% of patients received artemisinin-based combination therapy (ACT), but it should be noted that this survey was completed prior to the introduction of ACTs in Uganda. The proportion of women receiving two doses of intermittent preventive treatment in pregnancy (IPTp) was 16%." The US/ Uganda Country Plan for Malaria is here

The service delivery challenges facing the implementation of the national policy are numerous. Malaria, if that is the cause of the febrile symptoms, is a combination of a vector (mosquito), a person with malaria parasites in their blood, a 'bite' from the mosquito, the parasite's cycle within the mosquito, and a 'bite' of a person who was not protected by net, long sleeved clothing or another barrier method. Vectors can be deterred by Indoor Residual Spraying, or scents (lemon) and chemicals (DEET or Pyrethrum), or nets - preferably insecticide treated nets. For Ugandans, long term prophylaxis are not an option, although the ancient Chinese practice of drinking a tea based on the Artemisia plant is gaining some interest. Despite IRS campaigns, compounds around houses being kept dry and free of places for mosquito to breed, and even in areas of high net usage, fevers occur and malaria parasites are blamed if not also being a likely cause. Without effective recording of the results of all febrile laboratory tests, or vastly increased access to RDTs, malaria will continue to be assumed by patients and policy makers as the driver for fevers. This also means that malaria is a major contributor to neonatal deaths.

For a national health service, the availability of ACTs - a drug that works effectively to kill the parasites in an affected person and will lead to their recovery - is a balance of a finite supply of courses of ACT treatment and the needs of an individual patient/ guardian carrying a child with a fever and no means for parasitological testing. Most medics would reasonably make a clinical assessment and as ACTs do not harm that patient, perhaps prescribe ACT just to be certain. Free to client ACTs without free to client RDTs or lab testing places huge medical ethical pressure on a clinician whilst the public health consideration remains when the ACTs stocks will be replaced as proven malaria cases will need them. Hope Clinic Lukuli has been interviewed as part of a US National Public Radio programme on these pressures.

Our desire is to expand the availability of free to client RDTs throughout the community at every drug shop where a patient might try to self-prescribe and guess the cause of the fever. Through The Global Fund Round 10, Uganda will implement its policy for RDTs at health centres III and we hope that we will be able to bring those free RDTs to our community.