Attachment J.8-UMRESP.docx

THE UGANDA MALARIA REDUCTION AND ELIMINATION STRATEGIC PLAN 2021-2025

Ministry of Health Plot 6, Lourdel Road Nakasero P. O. Box 7272, Kampala, Uganda

March 2020

TABLE OF CONTENTS

Foreword Acknowledgements Abbreviations/Acronyms Executive Summary

Chapter 1: Introduction

1.1 Country Profile

1.1.1 Geography, Ecosystem, environment and climate:

The Republic of Uganda is a landlocked country located within the Great Lakes region of East and Central Africa. It shares Lake Victoria with Kenya and Tanzania and Lakes Albert and Edward with the Democratic Republic of Congo (DRC). It is positioned between 1° south of the Equator and 4° north. There are presently 135 districts (Figure 2.1).

Figure 2.1: District Map of Uganda

Uganda has a total surface area of 241,550.7 square kilometres (sq.km), of which 1360.02sqkm (0.6%) is built-up areas, bush land constitute 19,723.25sqkm (8.2%),agriculture land constitute 105,317.21sqkm, about 43.6%, Grasslands 51,051.6sqkm (21.1%), Forests 19,535.3 (8.1%) water bodies 36,864sqkm (15.3%) and wetlands 7,620.8sqkm (3.2%)[footnoteRef:1] [1: (UBOS, 2018)]

1.2 Demography:

By 2014, Uganda’s population was estimated to be 34.6 million and has been increasing at an annual rate of 3% per year and is estimated to be 40 million in 2020 (UBOS, 2018)[footnoteRef:2]. It is estimated that by 2025, the population of Uganda will be about 50.2 million people. The Population Density of Uganda in 2014 was 173 persons per square kilometre, a two-fold increase from the 85 persons per square kilometre in 1991 (NPHS 2014)[footnoteRef:3]. [2: UBOS 2018] [3: NPHS 2014]

1.3 Socio-political system and malaria control

Uganda has continued to enjoy political stability since the inception of the National Resistance Movement in 1986 to date. With the political will for health in general and a malaria free Uganda, the President listed malaria as one of the diseases targeted for elimination in his 2016 Manifesto. With the ensuing stability in the country after a number of years of political instability, populations hitherto leading nomadic life or destabilized by internal wars are gradually settling in places previously abandoned. The need for better planning for health service delivery including malaria control through establishment of structures that will manage the disease in the newly established settlements. In the last 30 years of the current governance, there has been significant progress of Human Rights and Gender issues that has led to the observed political stability. The citizens have continued to enjoy freedom of expression, and feedback on public health interventions.

Malaria control has remained a priority action within the national health agenda of Uganda. The National Health Policy II (NHP II) and the Health Sector Development II (2021-2025) position malaria among the programs of national interest with NDP III providing for a special focus on malaria under national Objective 3: “To improve population health, safety and management and specific action 1 covering malaria: “Prevent and control Non-Communicable Diseases and communicable diseases with focus on high burden diseases (Malaria, HIV/AIDS, TB) and epidemic prone diseases”. At the highest level, H.E the President is an active member of the African Leaders Malaria Alliance (ALMA) and has personally signed to and launched the Mass Action Against Malaria (MAAM) approach to drive the country’s elimination agenda. In order to ensure that malaria control is on the national agenda, a Parliamentary Malaria Forum was formed with the Right Hon. Speaker of Parliament as its patron.

The Government has set up favourable policies to ensure that malaria is controlled and eventually eliminated in the country such as abolition of user fees thus free treatment in all public facilities and waiving of government taxes on ITNs, medicines and laboratory supplies in 2001.

1.4 National development priorities

The National Development Plan III (NDPIII; 2020-2025) outlined five Development Objectives to achieve the Goal to increase average household incomes and improve the quality of life of Ugandans[footnoteRef:4]. In pursuit of the industrialization agenda, proposed NDPIII’s objectives are based on the country’s comparative advantages that lie in its abundant natural resources and young population, the achievements registered so far from investments in productive infrastructure as well as the partnerships forged between the public and private sectors. These objectives meet the purpose of accelerating growth of the economy, transforming the lives of the people and strengthening the country’s regional and international competitiveness on four main National Development Priorities: [4: NDP III (in Draft form)

(i) Increased agricultural production/productivity and agro-processing, mineral beneficiation and mineral-led industrialization, oil refining, tourism expansion, and labour-intensive light manufacturing (including cottage industries).

(ii) Sequential and coordinated infrastructure investments in energy, roads, water, air, rail, industrial parks, and mechanized irrigation schemes to support increased production/productivity for export expansion and the production of goods that are otherwise imported.

(iii) Increased generation of more skilled, better motivated and healthier workforce for all sectors of the economy, but particularly for industrial sector as well as a modernized agricultural sector and

(iv) A strengthened private sector that is able to drive growth and investment in collaboration with the state.

The Health Sector Development Plan 2020-25 (HSDP II) The Health Sector Development Plan 2020/21 – 2024/25 (HSDP II) provides the health sector commitments and priorities for the 5 years from FY 2020/21 to FY 2024/25. It is fully integrated in the overall National Development Plan 2020/21 – 2024/25 (NDP III) and the country’s aspirations expressed in the Uganda National Vision 2040. The MSP will reflect the four main elements of Health Sector Development elements of a) Health Promotion, b) Disease prevention, c) Curative services and d) Rehabilitation.

1.5 International Commitments

The African Union Heads of State jointly stated their commitment in 2000 during the Abuja Declaration, calling for “Universal Access” to HIV/AIDS, Tuberculosis and Malaria services by 2010. All policies and strategic plans have always been aligned to the WHO and Roll Back Malaria (RBM) guidelines and targets especially those stated in the Global Technical Strategy (GTS), The Action and Investment to defeat Malaria (AIM) as well as the Sustainable Development Goal (SDG) targets under Goal 3 “Ensure healthy lives and promote well-being for all at all ages”, specifically target 3 “By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases”. Being one of the top ten high burden countries for malaria, the country has embraced global and regional commitments in malaria prevention and control initiatives such as the High Burden High Impact (HBHI) strategy which was first launched in Uganda in 2018.

1.6 Socioeconomic situation

Malaria is a disease that disproportionately effects the poor and the economic status of populations at risk has proved to be a great challenge in malaria control programmes (Heggenhougen et al., 2003). This is evident in Uganda where malaria affects disproportionately the poor. Nearly 58% of malaria deaths occur among the poorest 20% of the world's population (Gwatkin D et al., 2000). Endemic malaria results in tremendous economic losses annually and is a central element of the vicious cycle of poverty in many developing countries (Dhiman SK, 2009) and Uganda subscribes to this category of countries. At the end of 2017/18 fiscal year, the GDP of Uganda was estimated at UGX 100.5 trillion (UBOS, 2018). The per capita GDP was estimated to be about USD$799 which literally means households survive at less than USD 2 per day which leaves the much of the population living in poverty. Based on the 2016/17 survey data, an estimated 27 percent of Ugandans (10 million persons) are poor, leaving a quarter of Uganda’s population susceptible to malaria risk irrespective of other predisposing factors.

Housing conditions and malaria preventive interventions Nationally, 79% of households have a finished roof defined as roofing materials composed of iron sheets, wood, asbestos, tiles, concrete, and roofing shingles. The wall material plays an important role in ensuring that IRS is a success at household level. According to MIS, 2019 about 54% of the households have rudimentary walls defined as rustic mat, wood planks, cardboard, or tarpaulin wall materials. This implies that only 46% of the walls (3.4million HHs) are suitable for the application of IRS. Improved housing characteristics, such as finished roofs and walls, reduces the risk of malaria transmission (MIS, 2019).

Transport and Communication infrastructure and malaria interventions Thirty-four percent (34%) of the households had observed better living conditions attributed to improved transportation services (UBOS, 2018). In Karamoja, only 11% of the roads are in improved condition. Better infrastructure like transport in terms of better road network, modern communication equipment and latest information technologies are likely to accelerate access to malaria prevention and care services among the population and improve human well-being.

1.7 Health System Structure:

1.7.1 Administrative and Governance structures

Uganda is stratified into a hierarchy of administrative units namely: Districts, Counties/Constituencies, Sub-Counties, Parishes and Villages. There has been a rapid proliferation of sub-national administrative units in the country. To date, there are 135 districts as at 1st July 2019. Furthermore, there are 255 counties, 10,011 sub-counties, 68,649 villages and about 7.3 million households. See Figure 2.3.

The Minister of Health is the overall political head of the ministry of health supported by the two Ministers of State, one for general duties and the other for primary health care. The Permanent Secretary is the administrative head of the ministry while the Director General Health Services (DGHS) is the technical head. Below the DGHS are Directors overseeing several Departments that constitute the planning units or Votes of the ministry and are headed by Commissioner of Health. The disease specific and other public health programmes are at the level of Divisions and headed by Assistant Commissioners of Health including that for malaria. In the NMCD the programme manager is supported by a technical and management team to lead, manage and coordinate the planning, implementation, monitoring and evaluation of the performance of the national programme. The 12 Regional Referral Hospitals serve as the nearest technical support and supervision for the district health systems.

The Chief Administrative Officer (CAO) and District Health Team (DHT) are responsible for the strategic and operational management of the district health services in collaboration with civil society, private and community-based health service providers.

1.7.2 MOH organogram and the linkage of NMCD

The Director General Health Services (DGHS) coordinates technical functions for delivery of health services. The work of the DGHS is coordinated through two directorates: Directorate for Planning & Development and Directorate of Clinical & Community Health services where the Department of National Disease Control that host the National Malaria Control Division resides.

Several semi-autonomous government agencies complement the work of the Ministry in discharging its core functions through service delivery, research and training, and procurement and distribution of drugs. These include both parastatals, and statutory institutions responsible for quality control. These are: Health Services Commission, National Drug Authority (NDA), National Research and Teaching hospitals– Curative services and teaching, National Medical Stores (NMS) – Procurement and distribution of commodities, Uganda National Health Research Organization (UNHRO), Uganda Virus Research Institute (UVRI) – Research, Uganda National Chemotherapeutics and Research Institute (UNCRI), Joint Clinical Research Centre (JCRC), Uganda Blood Transfusion Services (UBTS), Uganda Medical and Dental Practitioners Council, Pharmacy Council, Uganda Nurses and Midwives Council and Allied Health Professionals Council as shown in the figure below. Figure 2.2: Organogram

1.7.3 Health care delivery system

As stated in Uganda HSDP II (2021-2024), Uganda has a mixed health-care system, inclusive of public, private health-care service providers and the traditional and complimentary medicines practitioners (TCMPs).

The Uganda system offers tiered health care services across 6 levels, from National Referral Hospitals (NRHs), 2 in number, through 14 Regional Referral Hospitals (RRHs), 153 General Hospitals (GHs) and 215 Health Centre (HC) IV providing referral services to 1,510 HC III and 4,208 HC II providing basic health care up to the 72,000 Village Health Teams (VHTs) at community level.

At all levels, malaria services are provided. Therefore, in the period 2021-2025, the program will maximize the existing governance, leadership and management structures to reduce and eliminate malaria in Uganda.

The District Health (including the urban authorities) System is the core building block of the National health system in policy and legislation for geographically defined populations Table 1.1: Health Care System by Level

Figure 2.3: The Uganda Government, Health System and Health Care Structure by Level

Figure 2.3: The Uganda Government, Health System and Health Care Structure by Level

The colour code reflect the administrative hierarchy

National Level The Ministry of Health is mandated to provide stewardship and leadership of the health sector and is responsible for policy review and development, supervision of health sector activities, formulation and dialogue with health development partners, strategic planning, setting standards and quality assurance, resource mobilization, advising other stakeholders with defined roles to play in the implementation of the strategic plans.TheMoH has defined the functions and responsibilities of each level of health care and set the minimum service standards and staffing norms for each level.

The Regional Health System The regional health system comprises all key health actors within the region coordinated through the Regional Referral Hospital (RRH) community health department. The RRH is headed by the Director and heads of departments for all health service delivery points.The public health programs of the regional referral hospital are coordinated by the community health department that is responsible for health promotion, disease prevention, and specialist outreach curative services..The District Health Service Delivery System The district health system (DHS) encompasses public and private general hospitals, health centres as well as civil society community health programs managed by the District Health Team (DHT) under the stewardship of the District Health Officer (DHO). The District Local Governments and DHO have the responsibility for the delivery of health services, recruitment and management of the personnel for district health services. In addition, they are tasked with development and passing of health related bi-laws, planning, budgeting, resource mobilisation and allocation for health services.

The district health system is made up of five tiers with clear roles and responsibilities in delivery of the minimum health care package under the stewardship of the district health officer and the health sub districts In-Charge. The District health system should be the entry point for establishing a District malaria control unit with a core team of technical staff to support sub-districts within their catchment area.

The General Hospital The General Hospital, headed by a Medical Superintendent and staffed with medical and other allied health and nursing cadre, provide clinical services in both outpatient and inpatient departments including malaria services Some general hospitals also head health sub districts through their community health departments to coordinate the provision of primary health care services and supervise lower level health units in the district.

Health Centre IV Within the district, the health system is further sub divided into health sub districts (HSDs) that have headquarters at health centres level IV or general hospitals. The HSD provides overall day-to-day management and technical oversight of the lower level health facilities (HC level III, II and community level) within its jurisdiction. Currently, technical and financial capacity to provide leadership in technical and management functions is inadequate. The HCIV serves as community referral facility with provision for emergency surgery and blood transfusion services.

Health Centre III HC IIIs provide basic preventive and curative care as well as provide support supervision of the community and HC IIs under its jurisdiction. These are: provision of laboratory services for diagnosis, maternity care and first referral cover for the sub-county. VHTs are geographically mapped with HC III.

Health Centre II The HC IIs provide outpatient care, community outreach services and linkages with Village Health Teams (VHT).Health workers at HC IIs supervise and mentor the village health teams (VHT), provide medicines and other commodities and receive referred cases from the VHT level for the parish.

1.8 Community level system

A Burden of Disease (BOD) study[footnoteRef:5] showed that slow progress in the UHC coverage are related to community and household determinants of health, accounting for 75% of preventable diseases. ). The HC I do not have a physical structure but rather consists of a team of community Health Workers known as Village Health Teams (VHTs) who links community to health facilities. Other community systems include traditional and complimentary medicines practitioners (TCMPs) and cultural and religious institutions, community groups and other civil society organizations (CSOs). Each village has five (5) member VHT selected by that community that are expected to serve between 20 and 30 households Two of them focus on iCCM. About 50% of all districts have functional iCCM- VHTs. The role of VHTs is facilitating community mobilization, and empowerment for engagement in health. [5: WHO &WB, 2017. Computed using 2015 Data]

Chapter 2: Malaria Situation Analysis

2.1 Demography and malaria risk

The entire population of 40 million is at risk of malaria with 95% in areas of stable transmission and 5% characterised as area of unstable transmission. In 2019, malaria accounted for 30-50% of outpatient visits, 15-20% of hospital admissions and up to 20% inpatient deaths.[footnoteRef:6]However, in the last 10 years, there has been a significant reduction in malaria prevalence from 42% in 2009 to 9% in 2019 (MIS reports). [6: Annual Health Sector Performance Report, 2018)]

The most at risk population remains children less than 5 years of age, pregnant women, non-immune visitors, immune compromised people, people with sickle cell disease and those who have had splenectomy or Hyper-reactive Splenomegaly Syndrome (HSS). However, recent surveys have demonstrated that children aged 5-15 years old are also more at risk than previously thought (PRISM, PBO Study)[footnoteRef:7]. As transmission dynamics changes and intensity reduces over time, age patterns of immunity may be also change, and severe disease may concentrate in older age groups. Uganda NMCD will collect the relevant clinical and epidemiological data so that health workers are continuously informed on any changes in risk groups. [7: PRISM, PBO Study (reference is needed in full)]

In addition, Uganda hosts about 1.411 million refugees and other immigrants that are settled in 13 districts and urban centres. In the early stages of the humanitarian response efforts the Office of the Prime Minister (OPM) and United Nations High Commissioner for Refugees (UNHCR) have been providing humanitarian health services through implementing partners in collaboration with the refugees hosting districts. In line with the Comprehensive Refugees’ Response Framework (CRRF), the ministry of health and partners have developed a 5-year integrated health sector refugee’s response plan that includes malaria control interventions.

There are also mobile and hard to reach communities including nomads, fishers that should be taken into consideration in the provision of comprehensive malaria prevention and control services to the community.

1.1

2.2 Meteorology and malaria transmission

The malaria burden in Uganda is largely influenced by the tropical climate, mainly rainfall. The regions of West, Central and Eastern Uganda experience two peaks of rain fall from March to May and from September to December. The northern parts of the country experience less rainfall and have one rainy season in the year. The peak of malaria transmission coincides with the peak of the rainfall season which is also the planting and harvest seasons when demand for labour is high. The annual rainfall varies from 500 to 2,800 mm, with an average of 1,180 mm. The far north-east of Uganda receives little rain during all months of the year.

Uganda’s location along the equator means that it experiences moderate temperatures (around 21°C throughout the year, with monthly temperatures ranging from 15°C in July in the south, to 30°C in February in the north and north-east. Uganda experiences stable endemic malaria in 95 % of the areas of altitude 1200 to 1600m.

Malaria transmission is perennial with two peaks, after the rainy season, (April – May) and the period between October-November. Temperatures between 20 and 30 degrees centigrade and relative humidity of 60% provide optimal conditions for malaria transmission.

2.3 Poverty and malaria

Macro-level estimates show strong links between malaria and poverty, and increasing evidence suggests that the causal link between malaria and poverty runs in both directions. The characteristics of the rural environment may also make malaria control difficult high receptivity, poor housing, dispersed nature of malaria vectors breeding sites and poor literacy (Yadav K et al., 2012). Karamoja, the most remote region in the country, has the highest prevalence of malaria, (34% malaria prevalence). Over 60% of the people in Karamoja live in poverty with under low socio-economic conditions.

In contrast the country’s capital (Kampala) has the lowest malaria prevalence of 0.5%, highest literacy (93.3%) and the lowest poverty index (5.9%). However, micro-level (household and population) analyses on the linkages between malaria and poverty have often produced mixed results. A poor malaria-stricken family may spend up to 25% of its income on malaria prevention and treatment. It is estimated that 40% of health expenditures in Sub-Saharan Africa are spent on malaria treatment (Ministry of Health, 2007).

Malaria not only affects their health but also their incomes as well as food security at household level. It is estimated that workers suffering from a malaria bout can be incapacitated for 5-20 days. In Uganda, a single episode of malaria costs a family on average 9 US dollars, or 3% of annual income. Further, severe malaria impairs children’s learning and cognitive ability by as much as 60%, consequently affecting the performance of Uganda’s universal primary and secondary education programmes (J. Nankabirwa et al., 2014).

2.4 Major economic activities and malaria

The high malaria infection generally can be explained by ecological factors such as fresh water, floodplains, swamp and upland rice fields, higher temperatures and lower humidity. Studies have shown that swamp rice fields are important habitat for mosquito larvae (Ijumba JN, 2001). Over 80% of the Ugandan population is employed in Agricultural sector. The lack of adequate manpower during the peak of agricultural activities decreases productivity and hence lowers income and aggravates food insecurity (WHO, 2003b). Other non-health sector projects including dams, mining, oil exploration, sugar cane plantations, road constructions are likely to increase transmission. This implies that efforts to reduce malaria burden need to include other sectors in a multi-sectoral approach.

2.5 Migration practices and malaria transmission

According to UBOS, 2018, Kampala had the highest percentage of persons who had lived in another place (31%) while Kigezi, Elgon and Bukedi had the lowest at 5% each respectively. Furthermore, Kampala and Kigezi regions had the lowest malaria parasite prevalence of less 1%. Kampala experiences influx from other regions of higher burden resulting in high number of malaria cases. Rather than migration, the socio economic characteristics of migrants predispose them to malaria infection. Therefore, understanding the changing socio-environmental situation as well as population movements and their associated risks for malaria infection, is critical for malaria control, containment, and elimination.

2.6 Human Rights and Equity Barriers to access and utilization of malaria Services.

An assessment undertaken in 2019 by the Ministry of Health to establish human rights and gender-related barriers to HIV, Tuberculosis and malaria services in Uganda asserts existence of human rights and equity barriers. Marginalized populations including vulnerable and underserved populations, such as the poor, most at risk populations (MARPs) and hard to reach areas. Others include children under five years and pregnant women, people living with HIV, people with disabilities, inmates and other detainees, people in closed/congregate settings, migrant and mobile populations, internally displaced populations, refugees and asylum seekers, older persons and people affected by ethnic, geographical or cultural barriers, with limited access to malaria services. Ministry of Health will be guided by the principles of equality and non-discrimination, do-no-harm, privacy and confidentiality, meaningful participation and inclusion of people affected by the disease and key and vulnerable populations and respect for personal dignity and autonomy. NMCD will ensure that all Ugandans, in their diversity are given fair opportunity to attain their full health potential through the identification and resolution of equity barriers within the context of malaria.

2.7 Urban malaria

The urban population has been increasing overtime from about 1.7 million in 1991 to nearly 7.4 million in 2014 (NPHS 2014) with a corresponding increase in urban centres from 67 to 259 (UBOS 2014)[footnoteRef:8]. By 2018, the urban population rose to about 18%.Uganda’s high urbanization rate (5.2 per annum) is largely a result of population growth and rural to urban migration. It is expected to continue to increase as the country industrializes further. [8: UBOS 2014]

Malaria transmission and burden in urban areas has reduced over the years but clusters in some areas experienced high receptivity. Malaria prevalence was approximately three times lower in urban (4%) compared to in rural areas (11%) according to UMIS (2018).

The 2021-2025 strategic plan will focus on urban malaria by addressing the following challenges: (i) reduced population immunity as a result of low exposure to infection which leads to high risk of epidemics and severe disease; (ii) High rates of imported malaria due to population movement leading to challenges in sustaining transmission reduction and progress to elimination; (iii) Sub-optimal and inequitable access to interventions and services due to rapid migration without corresponding planning and development; and (iv) Negative socio-cultural context (low perception of malaria risk and non-use of preventive interventions, presumptive treatment of all fevers with ACTs, harder to reach population with traditional malaria messages/interventions.

2.8 Integrated Approach to Malaria Response

The 2017 MTR of the UMRSP indicated high level of fragmented programming and implementation. NMCD did not adequately embrace public health and multisectoral nature of malaria response. Thereafter, NMCD and partners improved its working collaboration with other MOH departments, health related MDAs, partners and community resource structures community civic organizations to empower and ensure households are engaged in malaria response. Several strategies and guidelines including Uganda Parliamentary Forum for Malaria Strategy, MAAM Implementation Framework, Integrated Community Case Management (iCCM), Integrated Health Sector Refugee’s Response Plan, Multisectoral Action Framework, Private Sector Strategy and the MOH’s Supervision, Performance Assessment and Recognition Strategy (SPARS) Implementation Guidelines[footnoteRef:9]were developed and guided implementation of integrated approach to malaria response. Recently, the MOH established some cross-cutting Departments including Collaborations and Partnership. These integrated approaches, guided by the MOH leadership, this malaria strategic plan will intensify integrated approach and leverage others’ expertise and competencies to strengthen malaria response. [9: http://library.health.go.ug/publications/medicines/supervision-performance-assessment-and-recognition-strategy-spars-0]

Multi-sectoral approach and access to malaria services Uganda has a long history to multi-sectoral responses to disease outbreaks and public health threats, providing an established platform for the lessons learnt of a multi-sectoral action approach for malaria. Previously, Uganda has had multi-sectoral approaches initiatives in HIV/AIDS prevention, Anaemia, and Nutrition among others. Guidelines to mainstream malaria in the National and District Development Plans (2020)[footnoteRef:10] was developed and disseminated in collaboration with MOPFED and MOLGs. A budget call circular was issued by MOPFED to all sectors on support to malaria response. The multi-sectoral guidelines provided guidancein planning, management and performance monitoring to all sectors on malaria response towards a Malaria freeUganda. This approach is in response to the urgent need to put in place sustainability mechanism to maintain and improve on the gains achieved during 2014-2020 UMRSP implementation. In the 2021-2025 strategy, NMCD will enhance multi-sectoral approaches to improve access and utilization of malaria services (See Figure 2.4). [10: MOH/NMCD (2020): Guidelines to mainstream malaria in the National and District Development Plans (2020)]

Figure 2.4 Conceptual frameworks for malaria multi-sectoral action

2.9 Private sector and access to malaria services

Findings from the 2017 MTR of the UMRSP indicated minimal adherence to national malaria policies and guidelines in the private sector[footnoteRef:11]. It further noted failure to engage actively with the private sector despite its huge potentials. In Uganda, up to 62% of the population first seek health services including for malaria and febrile illnesses from the private sector (48.4% from Private Hospital/Clinic and 13.6% from private pharmacies),rising up to 70.4% in the urban population[footnoteRef:12]. [11: MOH (2017: 2017 Mid Term Review of the UMRSP 2014-2020; MoH, Kampala, Uganda] [12: UBOS (2017): Uganda National Household Survey 2016/17]

This strategy will adopt the Universal Health Care (UHC) principle of leaving no one behind and constructively engage private sector and maximize its potentials including for malaria response and health development. It will leverage on private sector initiatives in areas of innovation, creative financing, corporate social initiatives and ethical and moral issues which were not being utilized previously to increase access and utilization of malaria services.

2.10 Policy and programming environment

Building on the previous gains, NMCP of Uganda has updated its malaria control policies in 2018 to respond effectively to the epidemiological situation, accelerate the fight against the diseases: reflect the strategic direction of malaria prevention. The midterm review of 2017 recommended an accelerated implementation approach in Mass Action Against Malaria (MAAM) in line with the High Burden High Impact (HBHI) Approach. Other enabling programmatic environment were listed in the recommendation. By 2019, the MPR observed that most of the condition precedents were not met. Going forward, 2021-2025 Strategic plan will focus on addressing those issues.

Chapter 3: Key Findings from 2019 Malaria Program Review

3.1 MPR Process:

In 2019, a comprehensive review of the malaria programme, using adapted WHO (2019) tool, was conducted to identify approaches and activities that worked well and achieved results, as well as lessons learned especially on areas that need improvement, with a view to strengthen the program and re-position the programme for impact.The review, highly participatory, was executed in phases: Planning, Thematic desk review, Validation and Programme strengthening. Specifically the MPR reviewed the: a) progress of the national malaria control programme towards the epidemiological and entomological impact targets of the UMRSP; level of financing of the national malaria programme; c) capacity of the national malaria control programme to implement planned activities; d) attainment of programme outcome targets; and defined the programming implications of the lessons learned in the implementation of the UMRSP. An aide memoir, a commitment of the Government of Uganda and its partners, highlighting the conclusions and key recommendations, was endorsed. This review formed the foundation upon which this 2021 – 2025 was built.

3.2 MPR Key Findings:

Key findings from the 2019 MPR are listed here below:

3.2.1 Progress towards the epidemiological and entomological impact targets of the UMRSP 2014-2020 Uganda achieved notable epidemiological impact in reducing the malaria burden both in all-cause child mortality, malaria related-mortality, and malaria morbidity are summarized as follows:

i. The all cause under five mortality reduced from 90/1000 live births in 2011 to 64/1000 live births in 2016, a 30% reduction. The UMRSP target was 56 in 2014/15.

ii. Malaria-related death rate, based on routine reports, decreased from 30/100,000 (2013) to 9/100,000 (2019) persons per year, a 70% reduction. The UMRSP target is 5/100,000 (2020) persons per year.

iii. The proportion of malaria deaths out of total deaths in health facilities decreased from 18% in 2013 to 10% in 2019, a 44% reduction. The UMRSP target was 8% in 2019.

iv. Malaria incidence, based on routine reports, decreased from 460/1000 in 2013 to 342/1000 persons per year, a 26% reduction. The UMRSP target was 198/1000 persons per year.

v. Malaria parasite prevalence rate was reduced from 19% in 2014 to 9% in 2018 (MIS 2019), a 53% reduction. Where IRS was conducted the prevalence reduced by 90% (36% to 3%). The UMRSP 2020 target is7% parasite rate.

These burden reduction gains are not homogenous as there are significant regional variations. The malaria parasite rate ranged from <1% in Kampala to 34% in Karamoja (MIS 2019); and similarly, the under-five child mortality per 1000 live birth ranged from 64/1000 in Kampala to 102/1000 in Karamoja (UDHS 2016).

Plasmodium falciparum remains the predominant species of malaria (97% of cases) followed by a slight increase in P. malariae and mixed infection. Karamoja had the highest percentage of P.malariae at 19.6% (UMIS 2019).

Figure 3.1 Map showing malaria prevalence in various regions of Uganda a) MIS 2014, b) MIS 2019 (Maps to be redrawn same scale and colours for clearer comparison)

MIS 2018/19

Entomological impact A significant shift from An. Gambie and An. funestus to An. arebiensis has been documented in Tororo and other regions with IRS. These findings have significant implications on selection and deployment of vector control interventions given that An. Arebiensis is mainly an outdoor biter. In the other regions where LLIN is the main vector control intervention, An. gambie and An. funestus remain as the predominant vector species.

A pre and post intervention (LLINs and IRS) review, conducted between2013 and 2018 in Tororo, showed a significant reduction in annual EIR from 129 to 0 infective bites per person per year (p<0.001), showing a strong association with the decrease in incidence and mortality Entomological monitoring on insecticide resistance has demonstrated high resistance of anopheles mosquito to different classes of insecticides, mainly to pyrethroids.

3.2.2 Progamme Financing

The total 5-year budget of the UMRSP was US $ 1.3667 billion equivalent to about UGX 5 trillion. Approximately 63.8% of this budget was available for malaria programming, leaving a 36.2% unmet funding gap (UGX 1.81 trillion). Figure XX shows the financial contributions from different sources

Fig 3.2 Financial contribution to malaria programming financing

3.2.3 Capacity of the national malaria program to implement planned activities:

Overall, 79% of the 457 planned activities were either fully or partially implemented by the program with rate adjusted for quality of implementation at 48.2%. The follow up on recommendations on the previous MPR and MTR was sub-optimal as only 35% of the recommend were fully implemented, and 47.5% partially implemented as of December 2019.

Factors enabling performance included the availability of policies and guidelines at the national and sub-national levels; availability of human resources and malaria commodities; however, performance was hindered by: financing (availability and timely release); inadequate decentralization, and weak coordination processes; resulting in late delivery of services; and sometimes low quality intended results.

3.2.4 Effectiveness of the Health System in delivering malaria services:

1) Attainment of Vector Control Outcome Targets

· Two LLIN mass campaigns were conducted in 2014 and 2017; however universal LLIN access and utilisation remained below targets of 100% and 85% respectively. The proportion of population with one net per two people was 62% in 2014 and 54% in 2019 (MIS), and the proportion of population using LLINs was 69% in 2014 and 68% in 2019 (MIS)

· PBO net evaluation study demonstrated that PBO nets were superior to conventional nets by 27% and 16% in reduction of parasite prevalence in children 2-10 years old at 12 months and 18 months respectively post distribution

· IRS was implemented in only 15 of the 50 targeted districts due to funding constraints

2) Attainment of Malaria Diagnosis and Treatment Outcome Targets

· The proportion of suspected cases that received parasitological testing increased from 79% in 2013 to 91% in 2019 in the public sector.

· Proportion of children under 5 with fever in the last two weeks who received treatment with ACTs according to national policy within 24 hours of onset of fever remained 87%

· Integrated community case management (iCCM) was expanded from 33 districts in 2015 to 73 districts in 2019.

· The percentage of pregnant women receiving IPTp3+ increased from 17% in 2016 to 41% in 2019, still below the target although availability of SP has improved significantly (from 8% to 80%).

3) Attainment of Procurement Supply Management Outcome Targets

· The Proportion of health facilities that reported no stock-outs of first line anti-malarial medicines lasting >7 days in the previous month increased from 36% in 2015 to 91% in 2019, a significant improvement in availing life-saving ACTs.

4) Attainment of Surveillance, Monitoring and Evaluation and Operational Research (SMEOR) Outcome Targets.

· With the advent of DHIS2 as robust tool for HMIS and integrated surveillance, the monthly reporting rate by health facility has increased from 88% in 2014 to 95% in 2019 and timeliness from 58% to 89% during the same period.

3.3 Lesson learned implementing the UMRSP:

Programming Implications of the Lessons Learned in the Implementation of the UMRSP include:

· Adequate and sustainable financing is necessary for comprehensive implementation of interventions and gains sustainability

· Sustained intensive advocacy to translate political commitment to tangible resources is required at all levels

· Availability of quality data and consistent use at all levels is needed for evidence-based decision making to drive the country towards elimination

· The highly heterogeneous malaria burden requires stratification at national and sub-national levels to ensure appropriate tailoring of intervention mixes for the various epidemiologic and socio economic contexts of regions, districts and communities

· Changes in malaria epidemiology, population immunity, climatic conditions, and human activities are placing more areas at risk of epidemics, thus requiring further collaboration and integration with department of integrated epidemiology, surveillance and public health emergencies and Meteorological Authority for timely and effective epidemic preparedness and response.

· Adequate human resources in terms of numbers and up to date skills is essential for effective programme management at all levels of service delivery

· Adequate decentralization of the programme to the operational level is essential to enhance the programmes capacity to reach the communities and households with effective interventions

· Effective engagement with and coordination of other MOH departments, line ministries, malaria partners, the multi-sector, private sector and CSO’s is key to integration for improved service delivery

· The deployment of new approaches such as HBHI/MAAM to accelerate progress towards a Malaria Free Uganda has refocused the programme and brought together actors at all levels to take on responsibility for a malaria free Uganda.

· Migrant populations are a potential source of malaria transmission and place a burden on the already strained health services. The programme should integrate their needs during planning

3.4 MPR Recommendations and conclusions:

As a way forward, the malaria programming in Uganda should:

· Ensure malaria remains high in the political agenda with a sustained political will and multisectoral approach through the HBHI pillars (MAAM) from national to community level;

· Develop innovative ways to mobilize additional resources from internal and external sources to sustain malaria response, as well as promote technical and financial accountability of resources;

· Promote strategic use of information to drive impact at all levels through strengthened data management system including analysis, and use of data at sub-national levels including from analysing data in the: data repository for stratification and deployment of appropriate mix of interventions and expanding entomological surveillance

· Implement Epidemic Preparedness and Response Plan, fully integrated with IDSR using a multi-sectoral approach

· Decentralize and integrate malaria program at all levels through empowered district health management team (DHMT) to accelerate the implementation of MAAM / HBHI approaches;

· Promote community level engagement and ownership through ‟bottom-up” approaches including appropriate advocacy and behavior change communication to increase efficiency and effectiveness of interventions and gains sustainability;

· Operationalize the Private Sector Strategy and Multisectoral Action Framework for sustainable malaria response;

· Engage with neighbouring countries, East African Community, and regional economic commissions to address cross border malaria in line with the Great Lakes Malaria Initiative

Conclusions

· The significant reduction in the burden of malaria is commendable. However, the programme should accelerate current efforts in disease prevention and control adhering to the HBHI and MAAM approaches to achieve the elimination of indigenous malaria from Uganda by 2030

3.5 Intervention targeting and delivery for impact

In 2019-2020, an analysis of available body of evidence was conducted to support the development of the national malaria strategic plan for Uganda through the High Burden to High Impact (HBHI) approach. The analysis process involves two main steps. First, a stratification of districts was implemented based on important epidemiological metrics (parasite prevalence, malaria incidence and all-cause mortality in children under the age of five years) as shown in Figure 3.4. Second, the epidemiological information was combined with district level measures of seasonality, urbanization and access to care to identify core interventions to be implemented in each district. Criteria that linked the stratification to interventions was applied, resulting in a district level intervention mix map. The criteria applied in making these decisions are presented in the WHO technical brief[footnoteRef:13]. [13: WHO technical brief for countries preparing malaria funding requests for the Global Fund (2020–2022)]

Figure 3.4 Estimate of U5 mortality (2017), incidence (2019) and malaria parasite prevalence (2018) by district

3.5.1: Subnational intervention mixes for impact

After identifying intervention mixes by district, a further analysis, driven by contextual and operational considerations, was implemented to ensure appropriate delivery approaches were identified. In 2021-2025, four major interventions will be deployed in the country namely: CM, LLINs, iPTp and IRS. CM, LLINs and iPTp will be deployed in the whole country with different service delivery models while IRS will be deployed in the regions with a high malaria burden and high transmission. In the highly seasonal Karamoja region, seasonal malaria chemoprevention (SMC) will be evaluated in a selected high burden district, to investigate both the primary health impact of SMC, the levels of SP and AQ molecular resistance and the scalability of this intervention in the whole of the region. Similarly, in high burden northern regions, intermittent preventive treatment of infants (IPTi and IPTc) will be evaluated in selected districts. In urban areas, detailed microstratification will be implemented to improve targeting of interventions such as LLINs. Urban areas will also be considered priority for larviciding following a comprehensive geospatial and entomological surveillance to support efficient targeting of potential breeding sites. A subnational regional map of core interventions is presented in Figure 3.5.

Figure 3.5: Interventions mixes for impact

Note: LSM will be implemented, where possible, in urban areas as these areas are amenable to the high level of entomological and geospatial surveillance necessary to make LSM effective.

Figure 3.6 a) IRS MSP (2021-2025) Expansion plan Figure 3.6 b) IRS Districts 2021-2023

3.5.2: Interventions delivery approaches Service delivery approaches must be tailored to the epidemiological needs of populations as well as the systems by which local geographies are organized. It should be informed by social, cultural and behavioral factors.