Introduction

The National Malarial Control Programme (NMCP), Uganda commissioned this rapid assessment to gather evidence to help improve management of severe malaria, especially at the primary levels of the health delivery system. This follows the adoption of injectable artesunate (Inj AS) as a first-line treatment for management of severe malaria in both children and adults; and the further expansion of management of severe malaria in children to include the use of rectal artesunate (RAS) as a pre-referral intervention. The rapid assessment explored how Uganda can enhance case management of severe malaria at primary level health facilities (III & IV) which are closest to communities and should serve as the first point of contact for health services for many people.
The objectives of the assessment were to explore the capacity of severe malaria service delivery at selected primary level health facilities, identify challenges and opportunities for improving service delivery and provide recommendations on how identified gaps can be addressed.
The assessment was limited to 13 health facilities, including six level IV, six level III health centres and the Children’s Ward of Jinja Regional Referral Hospital (JRRH). Data used in the assessment was collected using multiple methods, including literature review, an audit of health facilities, and qualitative methods including health facility staff interviews, key informant interviews with village health teams, community level focus group discussions (FGDs), and consultation meetings with district and national stakeholders.

Results

Staff were performing the expected functions across all 13 health centres visited, including triaging patients, diagnosing and treating. Level III health facilities had shorter waiting times on average (between 5 and 30 minutes), while waiting times for some Level IV facilities were reportedly more than 2 hours. The quality of service provided by Level III facilities varied.
With regards to severe malaria management, most facilities mentioned that they had staff who had been trained in malaria microscopy or the use of RDTs. Most staff mentioned having received some form of training on Inj AS, while staff from only four of the 13 facilities mentioned that some training had been received for using RAS. Many were not aware of any training on RAS, nor on its use as pre-referral intervention. It was difficult to establish if a structured continuing medical education (CME) programme existed for health facility personnel in the four districts that were visited.
The first-line treatment for complicated malaria was mainly reported as Inj AS, however some health workers preferred to use quinine to artesunate. In many cases, stock outs were common; Inj AS was not available in three facilities and RAS was only available at three facilities. Shortages were attributed to irregular supply, especially at level III centres where the amount of stock is pushed out to health facilities in pre-determined amounts rather than requested based on need.

Discussion

The policy framework for the management of severe malaria in Uganda seems to be enabling adequate case management. However, results from this assessment point to critical gaps. The most important gap relates to policy guidance on which level should manage which manifestation of severe malaria, resulting in variations in the range of services offered between and within level III and IV health facilities. Policy advises that Inj AS be used only at level IV health centres, but was also found at level III health centres.
Basing on the observed staffing levels, equipment and drugs available, both level III and IV facilities managed limited cases of severe malaria, and both referred cases they could not manage. However, results show limited knowledge on pre-referral interventions at level IV facilities, although these facilities both receive referred cases and refer those they cannot manage. Our results suggest that RAS is required at level IV facilities and all levels below it, and Inj AS may be required at both levels III and IV.
Improvements in drug supply and monitoring are possible. The assessment results show that commodities required for treating severe malaria were not consistently supplied as required. Stock outs of malaria diagnostic commodities (reagents, blood transfusion, glucose sticks, RDT kits, malaria blood slides etc) were interfering with the management of severe malaria.
Lastly, facility level data on caseload, morbidity and mortality show that malaria fatalities increase as one goes up the levels of the health delivery system, which was largely related to a suboptimal referral system. Referred cases of severe malaria are resulting in the fatalities, and associated failure to manage cases at primary levels of the health system could be contributing to delays that result in the deaths.

Conclusions

Our assessment concludes that the case management for severe malaria at levels III and IV in Uganda, has room for improvement. Inj. AS has reached both types of facilities, but without adequate support in terms of training, reference materials and referral. RAS is currently placed at level III centres but could also be beneficial at level IV.
Recommendations

  1.  NMCP should consider updating treatment guidelines and protocols to provide clarity on the range of severe malaria conditions that should be managed at level III and IV facilities; by:
    1.  Ensuring adequate guidance
    2.  Ensuring that there is capability to provide a minimum set of services.
    3.  Rethinking and exploring the most appropriate positioning of RAS.
    4.  Working closely with the National Medical Store (NMS) to ensure consistent supply of commodities required for the treatment and pre-referral management of severe malaria patients.
  2.  The Ministry of Health should urgently ensure that the minimum set of services stipulated in the national treatment guidelines is capable of being met by these facilities. This includes ensuring facilities can provide necessary services required for treatment and supportive care. District Health Offices should draw up or update their plans for in-service training to include all the aspects of severe malaria as per treatment guidelines. This should include the administration and management training for lead persons at each health facility.
  3.  The Ministry of Health should review the existing referral system for severe malaria with a view to strengthening it. This includes exploring the appropriate balance between contributions from health facility users and the government.
  4.  As a strategy to reducing fatalities associated with severe malaria, the NMCP should urgently promote measures to ensure that level III and IV health facilities strengthen their management of simple malaria, as well as engage with the National Drug Authority (NDA) to ensure that the drug distribution system works efficiently.
  5.  To achieve the reduction in mortality rates for severe malaria, Ministry of Health, NMCP and stakeholders should start prioritizing severe malaria death auditing.

Acknowledgements

This report was developed by the Ugandan National Malarial Control Programme (NMCP), Ministry of Health Uganda in partnership with Medicines for Malaria Venture (MMV), Child Health and Development Centre, Makerere University, and Development Data. The NMCP requested support from MMV for the production of a report that would provide insights on how to improve current severe malaria case management practices at level III and IV health centres in Uganda. The rapid assessment documented in this report provides a quick outline of insights on how severe malaria case management can be improved. The NMCP and MoH of Uganda has consented to place this report in the public domain via the Severe Malaria Observatory and to be shared among partners.