Malaria Consortium UK - UGANDA

Evaluation of quality of malaria case management in the public sector after change in the Uganda national policy to ACTs as first-line treatment

In most of Uganda, malaria is highly endemic and is the greatest cause of morbidity and mortality. Malaria control relies heavily on prompt and effective treatment of uncomplicated disease. However since 1978 CQ resistance, resistance to other monotherapies such as sulfadoxine-pyrimethamine (SP) has spread throughout the sub-Saharan Africa region greatly destabilizing effective malaria control. Consequently, several countries changed their national treatment policies Artemisinin Combination Therapies (ACTs) because of their rapid action, lack of side effects and a reduction in malaria transmission. However the high unit cost, unavailability, comparatively complex dose regimens and safety profiles when used on a wide scale are concerns. Poor adherence and eventual development and spread of drug resistance are also concerns with their use. For these reasons, it will be important to monitor the uptake of ACTs at all levels in order to ensure maximum benefit is realised.

Uganda recently changed the first line antimalarial treatment to Artemether/Lumefantrine (Coartem ©). The study aims to define how Coartem© is used when deployed under operational conditions at Government (GOU) and private-not-for-profit (PNFP) health facilities for the management of uncomplicated malaria. This cross-sectional observational survey will be carried out in 4 districts in Uganda. The operational readiness of health facilities to implement the new antimalarial policy will be assessed, the case management practices of a sample of health workers will be examined and finally patient adherence with the new treatment will be assessed in a sub-group of randomly selected patients. Direct observation of consultations by silent observers who record performance of clinical tasks using a checklist; a structured interview with caretakers when they are ready to leave facility; and interviews with observed health workers about their working experience and exposure to in-service training, guidelines and supervision will be collected. The availability of medical supplies, particularly a detailed stock history of Coartem© and other antimalarials and equipment considered important for malaria case management will be recorded.

At follow-up, detailed questions will be asked on dosing schedules, diet during the preceding 4 days, pill counts, symptom histories and timing of symptom resolution, any adverse drug reactions will be measured.

The results will assist the Ministry of Health to monitor changes in malaria case-management following a change in the national drug policy and provide insights into optimal points of intervention to improve case-management practice and patient adherence. The final results will be presented to MOH and subsequently as a publication in a peer-reviewed journal.