The Changing Landscape of Malaria Case Management in Uganda: Decades of Struggle with Evolving Malaria Case Management Strategies and Drug Policies

Background: Uganda has some of the highest reported malaria transmission rates in the world. Methods: We reviewed published and un-published reports to provide a historical perspective and evolution of malaria case management strategies/policies in Uganda. Review findings: In the 1990s, uncomplicated malaria treatment was hampered by widespread parasite resistance to chloroquine (CQ) and sulphadoxine-pyrimethamine (SP). Paradoxically, faced with this challenge, the country changed the first-line regimen, in 2000, to CQ+SP and adopted home based management of fever (HBMF) for children < 5 years old. HBMF increased the proportion accessing CQ+SP within 24 hours from 7% in 2001 to 39% in 2003. However, after another policy shift, in 2004, to Artemether-Lumefantrine (AL), HBMF is to date implemented in only 34 of 112 districts. The private sector supports first treatment contact for 40-50% of fevers. However, engaging private sector providers remains challenging. Consequently, by 2011, only 30% of febrile children took AL on the same/next day after symptom onset. In 2011 there was a policy shift from presumptive treatment to parasite-based diagnosis. Following the policy change, the proportion of tests by rapid diagnostic tests (RDTs) increased to about 55% compared to 30% by microscopy. However a major challenge remains clinician’s adherence to test results. Reassuringly, AL remains efficacious. In 13 studies conducted between 2002 and 2010, the median PCR corrected day 28 efficacy was 98% (range: 71.9%–100%). However, counterfeit medicines remain a threat and the lack of an effective phamacovigilance system is concerning. A recent study demonstrated that 39% of sampled artemisinin combination therapies were counterfeits. Conclusion: Despite an increase in official development assistance over the last decade, by 2013 there remained gaps in national ambitions for universal access to prompt and effective treatment. A major challenge is the low profile of the national malaria control programme within the ministry of health structure which limits its capacity to coordinate multiple stakeholders. Secondly, there is a need for decentralized planning and implementation with greater involvement of the zonal, district, health facility and community levels. Finally, it will be critical to engage the challenging but very important private sector.