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Control it; don’t eradicate it

By Stephen Kafeero

Fighting malaria the wrong way kills 20 people every minute in Uganda

On December 19, 2011, a speeding lorry at Namanve, near Kampala city, hit a taxi and killed 6 of the 16 people on the taxi. Several others were injured. The story was headline news. There was national outrage. Everyone said “it was unacceptable” to let people die so carelessly and a speed monitoring point was set up immediately.

So why is similar outrage and prompt action not taken against malaria?

Statistics vary because most cases go unrecorded, but it is estimated that malaria kills between 100,000 to 200,000 people in Uganda every year. It kills between 280 and 560 people every day; that is the same as 30 taxis getting involved in accidents every day and all 420 people on board being killed. Imagine the chaos, outrage, and panic that would cause.


Malaria is the leading cause of disease and death in Uganda. The Malaria Consortium says it leads to severe economic losses, lost school days, and long-term disability.  On average, an individual in Ugandan has six malaria episodes per year. Malaria accounts for 33% of all outpatient hospital visits and 25% of all admissions.

Entebbe Grade B Hospital is a typical Ugandan health unit. Every morning it is a hive of activity as large groups of sick people swoop on its out-patients department and even spill out on to the grass. They all scramble to be registered handy with a 32-page exercise book. Individual medical forms are no longer provided because of the overwhelming numbers. Most patients are convinced they have malaria even before being diagnosed by a doctor.  Indeed, information from the Malaria Control Program indicates that 1in every 3 persons that visit a hospital in Uganda has malaria.

No wonder, many Ugandans do not care to go to hospital when they develop a fever. Most conclude it is malaria and self-medicate with serious consequences sometimes.

Agnes Nakitende lost her daughter to malaria in 2001.

“She developed a fever and I gave her Panadol (a GlaxoSmithKline trade name for paracetamol),” says Nakitende. The girl’s condition worsened and she died in the night.

Self-medication is common because although malaria drugs are supposed to be free in government-run health units, they are usually unavailable due to stock-outs or theft by health workers. Most end up in private clinics and hospitals where a dose of the recommended Artemisinin-based Treatment (ACT) costs over Shs 30,000; equivalent to a month’s salary of most casual workers.

Dr Gertrude .N. Kiwanuka of the Faculty of Medicine Mbarara University of Science and Technology says it is also important that the disease is diagnosed rapidly and correctly. This requires efficient medical practitioners, effective laboratory diagnosis, and fast and effective treatment, which are still lacking.

Mosquito nets are also expensive, costing between Shs 4,500 and Shs 12,000 and are  untreated. Nakitende now ensures that her other children sleep under Insecticide Treated Nets (ITNs) and she takes them to hospital when they fall ill. But most Ugandans do not use ITNs. As a result, the 2011 World Health Organisation statistics show that deaths due to malaria in Uganda are seven-times those of Kenya and 18% higher than of Tanzania.

Poor intervention

Unfortunately the government budget clearly shows a lack of interest in fighting the disease; in the Financial Year 2011/12, it allocated only Shs 7 billion to the health sector for the control of malaria and provision of drugs. Yet the same government, for example, budgeted Shs16 billion for intelligence gathering in the Office of the President.

As a result, most of the funding required for the health sector (Shs 877 billion according to a statement issued by Civil Society Organisations (CSOs) in March 2011) is shouldered by donors. This includes PEPFAR, GFTAM, and the Clinton Fund. An official of the ministry of Health says up to US$658 million (Approx. Shs1.5 trillion) is spent every year on malaria in Uganda. That is 50% more than what the government projects for its biggest budget item, the Ministry of Works. This huge figure raises many questions: What is it spent on? Why don’t malaria infections and deaths reduce in spite of this huge investment? Is the government’s donor-driven malaria control programme the best strategy?

Dr Meyers Lugemwa, an international health specialist and a senior medical officer at the Malaria Control Program says that Uganda has not achieved a lot because of poor implementation.

“We have all the policy guidelines to help us fight malaria but what is lacking is the effective implementation of these policies,” Lugemwa says.

Uganda’s malaria control programme has several main components: Diagnosis and Case management, Vector control, Intermittent preventive treatment during pregnancy, Social Mobilisation, Monitoring, Evaluation and Research, trend analysis, and Health Systems. In short, the programme focuses on treating the sick; case management, and preventing mosquitoe bites through distribution of Insecticide Treated Nets (ITNs) and Indoor Residual Spraying (IRS) or what the experts call “Integrated Vector Management”. The rest are support structures for this dual-pronged approach.

In spite of this intervention, up to 13 million cases of malaria were reported in Ugandan health facilities in 2010. That is three million more that were reported in 2005. The 2011 figures are not available but they are likely to be higher. So why is it not working?

Dr Lugemwa says the program is understaffed and lacks funds, especially from the government.

“The government needs to invest more,” he says.

Wrong strategy?

On December 13, 2011 the World Health Organisation released its annual malaria report that indicated that malaria cases were reducing throughout the world with some countries eliminating the disease totally. To understand why Uganda was not among the countries with good results, requires understanding how America, largest funder of Uganda’s Malaria Control Programme, was able to eradicate malaria in just four years.

It is not widely known in Uganda that until just 50 years ago America also had a malaria problem.

Between 1905 and 1910, the construction of the Panama Canal frustrated because of the 26,000 workers on the project, 21,000 suffered from yellow fever and malaria. The project succeeded after 1912 when the diseases were controlled and of the 50,000 employees only 5,600 fell sick.

America eliminated malaria through widespread IRS in just four years from 1947 to 1951. The Atlanta-based Centres for Disease Control and Prevention (CDC), which is a major player in Uganda’s malaria campaign, started out in 1946 specifically to eradicate malaria in the U.S. According to the official CDC information, by the end of 1949, over 4,650,000 housespray applications had been made. In 1947, 15,000 malaria cases were reported. By 1950, only 2,000 cases were reported. By 1951, malaria was considered eliminated from the U.S.

Soon after, in 1955, the World Health Organization (WHO) started an ambitious programme to eradicate malaria worldwide by focusing on house spraying with residual insecticides, antimalarial drug treatment, and surveillance in four successive steps: preparation, attack, consolidation, and maintenance. Unfortunately sub-Saharan countries were ignored in this campaign and WHO soon abandoned the eradication campaign and shifted to merely reducing the number of cases and deaths to a level where malaria is “no longer a public health problem”. That is the “malaria control” practiced in Uganda, Rwanda and other countries.

According to the CDC, some countries with the political will are once again focusing on malaria elimination and, ultimately, eradication. Uganda needs to follow suit.

Political will

Countries that registered success in the fight against malaria; including Rwanda, Zanzibar and Zambia have all used indoor residual spraying (IRS) on a wide scale combined with other strategies, including political will by their governments.

Dr Lugemwa says they have so far distributed 7.3 million mosquito nets for Uganda’s population of 33 million. They expect to distribute 10.1 million nets this year.

Mike Ndiema, the technical officer in charge of communications at the Malaria Consortium Uganda says that they are implementing a mosquito net distribution campaign both for universal coverage and for antenatal care. Universal coverage means 1 net per two people in a household. He is, however, concerned that the program is not countrywide. In cases where ITNs are given out free, some people refuse to use them, convert them into curtains, wedding dresses, or fish nets.

Indoor residual spraying (IRS) is used in Uganda but to a low extent. It has been used in about 10 districts in Northern Uganda including Gulu, Pader, Apac, Lira, where the annual  infective bites per person per year  is high and it has been very effective. However, research indicates that ITN and IRS are most effective if used concurrently.

Dr Gertrude .N. Kiwanuka of the Faculty of Medicine Mbarara University of Science and Technology says although it is welcomed by communities, IRS use is limited because the insecticide used is expensive and is usually donor funded.

“The Government of Uganda will have to step out and fund this control measure,” she says.

Funding

Funding malaria control programmes is likely to be a major issue going forward. A WHO report indicates that its budget worldwide is likely to reduce from US$2billion n in 2011 to US$1.5billion by 2015.This is alarming because the WHO projection for funds needed to fight malaria is about US$5billion per year.

In Uganda, according to the malaria operational plan for 2011 by the President’s Malaria Initiative, the government provided US$ 10.5 for malaria and requested the Global Fund for US$156 million. The report says, even if Uganda gets that money under the GF Round 10, a substantial funding gap would remain.

But Dr Christine Ondoa, the minister of Health says that the government is not alarmed over the dwindling donor funds to fight the disease projected by the WHO.

“We shall cross the bridge when we get there,” she told The Independent.

Unfortunately, it might be too late for some Ugandans. Every minute you spent reading this article someone died of malaria.

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