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.