10th May, 2006

Malaria rolls back success

By Richard M. Kavuma

Although Uganda is internationally recognised for battling HIV/AIDS, Malaria remains the leading health problem in the country.
The latest National Service Delivery survey found that more than 50 percent of people who had fallen sick in the previous one month suffered from Malaria.

According to Dr J. B Rwakimari, programme manager at the Malaria Control Programme in the ministry of Health, 52 percent of out-patients at hospitals and clinics are suffering from Malaria.

Surveys in 2005 show that malaria kills 110,000 Ugandans every year, 70,000 of them children below five years. This toll is more than a combination of deaths from HIV and TB

Women learning how to use a mosquito net: Nets could save millions of lives and money

And so Annet Nakibwami’s despair was understandable as her three-year-old son, Gonzaga Mawejje, gasped for breath on blood drip in Biikira Hospital last November. “He has not improved,” cried Nakibwami, 26. “He is as bad as when I brought him yesterday.”
The specific Millenium Development Goal target here is to have halted by 2015 and begun to reverse the incidence of malaria. But as the above figures show, the disease remains the leading killer in Uganda.

Rolling it back

In 1998, the Ministry of Health started the Roll Back Malaria campaign with four main strategies: Giving effective treatment to the community, preventing malaria in pregnancy using Fansidar, controlling mosquitoes using treated nets and indoor spraying, and monitoring malaria cases to detect upsurges.

At the time, malaria accounted for 40 percent of clinical cases in Uganda. Rwakimari notes that the data collection was still very poor. The increase in reported cases of malaria is partly due to population growth, better health information system, and government’s scrapping of cost-sharing, which encouraged more people to visit hospitals.

UN Secretary General Kofi Annan suggested in his 2004 Millennium Project Report that Malaria would be controlled if each child in a malaria-endemic region slept under a mosquito net. In 2001, official surveys showed that only 10 percent of children below 5 years could get effective drugs within 24 hours of noticing signs of malaria. Today, Rwakimari says it has risen to 65 percent.

This is partly because of the home-based treatment of malaria, where, “homapacks” of drugs are placed with identified resource persons in each village.

In her village at Buzira Nduulu near Kyotera town, Nakibwami had actually got the homapack three times without any improvement. When she took her son to Biikira Hospital, he was immediately put on blood-drip. But like other initiatives, the homapack needs to reach more homes to have a big impact.

Children below 5 using treated mosquito nets was being put at eight percent until May 2005. But quoting a May 2005 survey, Rwakimari said it had risen to 25 percent.

The number of pregnant women using Fansidar to prevent malaria has also risen from 10 percent in 2001 to 34 percent by the end of 2004.

In 2001, of the people who contracted malaria, 4.2 percent died of it; by the end of last year, surveys showed that 3 percent died. This “case fatality rate”, Rwakimari says, is a measure of the effectiveness of handling of malaria cases. The target is to reduce it to 1 percent by 2010.


Why malaria kills so many Ugandans, despite this abundant knowledge and successful interventions at pilot level, boils down to poverty.

Rwakimari says government doesn’t have the money to spread interventions to the entire country so as to get a “public health impact” on the disease.

An observable impact, for instance, requires 85 percent of Ugandans to use treated mosquito nets and 90 percent coverage of indoor spraying over five consecutive years.

Regarding medication, only 20 percent of Ugandans go to public health centres when they fall sick. The 80 percent use either self medication by buying drugs, go to herbalists or go to private sector hospitals. This means that a significant percentage of Ugandans may not benefit from government policy on effective drugs against malaria.

Besides cost, one cause for this has long been access to health centres. But Rwakimari says that today, 72 percent can access a health centre within 5 kilometres, compared to from 49 percent in 1986. With government having scrapped cost sharing fees, health-seeking behaviour has improved tremendously, but another problem emerged: hospitals without drugs.

“You go to the hospital but the doctor tells you ‘we have no medicines. Go to the clinic and buy them’,” complained Dominic Hasakya at Busolwe in Butaleja district.


Malaria is endemic in 95 percent of Uganda, meaning that people live perpetually with malaria. This leaves highlands like Kabale, Mbale, Kasese, Rukungiri as the potential epidemic areas because they don’t live with malaria.

Fighting abject poverty is critical to controlling malaria, because very poor households can hardly afford or properly use bed nets. Poor families also fail to buy and use the full course of treatment, increasing drug-resistance that is becoming a major issue in the treatment of malaria.

The Uganda NGO forum says in its report on MDGs that an average Ugandan spends 10 percent of his/her income treating malaria. In Kabale, the report says, it costs Shs 250,000 to treat malaria per person per year.

Way forward

One of the hurdles in the war against malaria is that cheap drugs are no longer effective. Government policy has since changed from Chroloquine and Fansidar to Artemesnin as the first-line of treatment for Malaria.

“We are hopping we could get these drugs, these are what we are waiting for,” says Rwakimari. “The only challenge we have is that they are expensive, 10 times more than the chloroquine.”
Similarly, many Ugandans like Annet Nakibwami cannot afford a mosquito net, while many of those who can afford it find it uncomfortable because of heat.

Government policy has been to encourage people to buy nets while it gives free nets to the very poor children under 5 and pregnant women.

Of all anti-malaria initiatives, none has caused more controversy than the proposed used of DDT. Environmentalists claim DDT is dangerous to humans and exporters fear Europe will ban Uganda’s agricultural exports once DDT is used.

Rwakimari says Europeans and Americans used DDT to eradicate Malaria and insists there is a window for it to be used in vector control.
“We are going to have it soon.

I wouldn’t put a time frame because we have to get the funds first,” he says. “What we are preparing is to put in place strong mechanisms to ensure that when we bring it in, it is not used by farmers for controlling their pests.”

Only in The Weekly Observer Next Thursday: Uganda's thirst for safe water and clean environment.