In Uganda, malaria remains a leading cause of illness, but all is not gloom

It is a country that is slightly over 90 per cent malaria-endemic. Rivers, human activity and poor drainage marry to create a perfect breeding ground for mosquitoes that transmit the killer disease.

In the streets, hawkers sell what would be considered an unusual commodity— bed nets. 

This is Uganda, where malaria is the leading cause of death.  The country ranks sixth in malaria deaths in Africa.

Yet nowhere in this country is malaria prevalence higher for children aged between six and 59 months than in Karamoja. 

Curiously, this area is semi-arid. The story of Karamoja is a contrast to Kenya’s, where high malaria prevalence is associated with lake regions and coastal areas.

In areas such as Busoga, where sugarcane and tea are grown, population density is a risk factor for malaria transmission and deaths. 

Busoga and Karamoja had the high prevalence of malaria in Uganda at 21 per cent and 34 per cent respectively in 2021, data from the country’s Ministry of Health shows.

 Meanwhile, West Nile recorded a prevalence of 22 per cent.

Dr Jimmy Opigo, the assistant commissioner in charge of malaria control at Uganda’s Ministry of Health, says cultural, societal and lifestyle factors are to blame for the high malaria prevalence here.

“The Karamojong are a pastoralist community. Many do not take precautions towards prevention of the disease. The community lives in manyattas, for instance, which aren’t ideal for using insect-treated bed nets,” he says.

But it’s not just lifestyle that contributes to the high malaria incidences in Uganda. Dr Opigo notes that in regions such as West Nile, human activity has over the years played a big part in propelling high rates of infection and deaths.

Tobacco farming is the main livelihood for locals here. But farming this commercial crop is also a health hazard as farms are a breeding ground for mosquitoes. Often, residents have to make the difficult choice between their livelihood and health. For many poor families, a means of living has to come first despite decades of suffering. 

When it was developed in the 1940s as the first of the modern synthetic insecticides, dichloro-diphenyl-trichloroethane (DDT) was initially used with great effect to combat malaria – among both military and civilian populations. Besides malaria, DDT was used to treat typhus and other insect-borne human diseases as well, and for insect control in crop and livestock production, institutions, homes and gardens. 

Its quick success as a pesticide and subsequent broad use in the United States and other countries led many insect pest species to develop resistance against the pyrethroid. 

Today, most government-issued bed nets in Uganda are still treated using DDT and pyrethroids, which renders them ineffective against the parasite. The result is a vulnerable population that risks contracting and dying from malaria. 

Dr Opigo reveals that the Health ministry is now considering home spraying in West Nile in an attempt to eliminate the drug-resistant malaria strains.

“We want to strengthen the health systems in the area and to mobilise the community to participate in malaria control activities. In any disease prevention, you only win the battle when communities demonstrate responsibility by taking the necessary steps,” he says.  

Dr Opigo says distribution of antimalarial drugs to children younger than five years during the rainy season, known as seasonal malaria chemoprevention (SMC), is one of the key interventions by the government of Uganda against malaria.  This includes administration of sulfadoxine–pyrimethamine and amodiaquine (SPAQ) to children below 59 months. 

In areas such as Kikoma in Kampala, doors of most homes are marked with chalk to show families whose children have been immunised.  This drug is recommended by the World Health Organization (WHO) for children in the age bracket, administered in monthly cycles during the season of highest malaria transmission. 

WHO estimates that the drug can prevent around 75 per cent of malaria cases in children in this group. Indeed, experts hail SPAQ for its safety and cost-effectiveness, and ease of administration by health workers and caregivers at the community level.

Kampala has a dense population in informal settlements,  which are affected by poor drainage systems. The city experiences cases of malaria  throughout the year, but they  peak during rainy seasons — from March-May and September-November.

But all is not gloom.  Data from the Health ministry show that there has been a substantial reduction in malaria prevalence in some regions such as Kampala and Kigezi, where the new incidence cases stand at less than one per cent.

Kampala is home to Mulago Hospital, the national referral hospital, which is also the teaching facility for Makerere College of Health Sciences. Whereas the city has slightly lower cases of malaria, the hospital administration admits that cases are diagnosed here every day. Like elsewhere in the region, admission of children and pregnant women is higher than that of men.

Net ownership and use varies widely across sociodemographic characteristics within the regions of Uganda.

A hospital administrator says clinically diagnosed malaria is the leading cause of morbidity and mortality, accounting to between 30 and 50 per cent of outpatient visits at health facilities.

He adds that between 15 and 20 per cent of all hospital admissions in Uganda are malaria-related. Meanwhile, malaria accounts for 20 per cent of all hospital deaths. The rate of death is even higher among children under five years, at 27 per cent.  

At the hospital, Healthy Nation meets with Maria Mashikomo and her five-months-old baby . The baby has been admitted here for nearly a week now after a positive malaria diagnosis. 

Ms Mashikomo, who comes from what is considered a crowded part of Kampala, says she does not have access to an insecticide-treated bed net. Neither does she have an idea about the seasonal malaria chemoprevention (SMC) given to the public by the Health ministry.

At the hospital, she has benefited from not only treatment for her son but education as well. Having given birth at a small dispensary in the village,  Ms Mashikomo had never benefited from education about her child’s healthcare before.
 
“I have learnt how to administer the drugs and make a record after every successful dose ,” she says.

She recounts that when her son was taken ill, she took him to a local pharmacy where she was given medicine for fever. “I feared he may have contracted Covid-19.”

While prevalence of malaria in Kenya and Uganda is different, efforts to fight the disease are nearly similar.

Like her neighbour Kenya, one of the biggest challenges in Uganda is insufficient funding for malaria. Both countries rely heavily on donor funding to combat malaria. 

Kenya, for example, which was lucky to be part of the  RTS,S/AS01 (RTS,S) malaria vaccine that was first launched in September 2019 in Ndhiwa, Homa Bay, received funding for the project. 

Kenya’s largest funding for malaria comes from Global Fund.

In 2020, donors at Global Fund’s Sixth Replenishment Conference pledged $14 billion (Sh1.5 trillion) to help save 16 million lives and end the epidemics of Aids, TB and malaria in Africa by 2030.  

The grant supplements government efforts against HIV, TB and malaria, and strengthens health systems at the national, county and community levels. Kenya, which had pledged $6 million (Sh660 million) contributed $2 million (Sh220 million) for the sixth replenishment. 

Meanwhile, Uganda, which had pledged $2 million,  made a contribution of only $77,976 to the global fund. 

Notably, the two countries draft their policies and expenditure plans based on when and if the funding is available.

For Dr Opigo, it’s difficult to quantify the amount of resources spent in the fight against malaria. A lot of money goes to the private care and also individual spending, he argues. 

“The last estimation of domestic funding has not been specific to malaria but it has also been underrated. Most of the efforts have been through individual prevention efforts such as installing own window screens and purchase of mosquito nets,” he says.

In Uganda, domestic funding has been low-rated to about 10 per cent, but this data is predominantly gathered from government facilities. In this country, more than 50 per cent of malaria-related services are sought from the private sector. According to the assistant commissioner, the public contribution in this fight is “much higher”. 

According to Dr Opigo, the Treasury hopes to allocate more funds and to leverage efforts through multi-sectoral action. One of these efforts is implementation of malaria smart actions through the Ministry of Agriculture.

“We also hope to have access to the Mosquirix vaccine like Kenya has,” he says. This vaccine has been found to prevent malaria infection by 39 per cent and severe cases of the disease by 29 per cent. It has also substantially helped to reduce overall hospital admissions. 

Introduction of SPAQ in the Sahel region of the country, now in the fifth phase, has recorded remarkable success. 

“We have made many efforts geared towards reducing malaria infections and deaths. We’ll continue to pursue interventions such as vaccination, which has been recommended by WHO,” he says.  

Trying biological methods to control vectors is one of the efforts currently being undertaken jointly between the Kenyan and Cuban governments at an estimated cost of Sh24 billion per year.

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