MINISTRY OF HEALTH. National Malaria Control Division. Annual Report July 2017 June 2018

Transcription

1 MINISTRY OF HEALTH National Malaria Control Division Annual Report July 2017 June 2018 i

2 To cite this report: Uganda Ministry of Health, National Malaria Control Division, Surveillance Monitoring & Evaluation Unit (2019), National Malaria Annual Report , Kampala, Uganda ii

3 MINISTRY OF HEALTH National Malaria Control Division Annual Report July 2017 June 2018 iii

4 Acknowledgement The development of the Malaria Annual Report 2017/2018 would not have been possible without the leadership of the National Malaria Control Programme and technical support from World Health Organisation. The process has been participatory involving ministry and implementing partners. The Ministry of Health wishes to acknowledge input of the following implementing partners who provided valuable information regarding development of the report: WHO, UNICEF, Malaria Consortium, MAPD Project, RHITES-SW, RHITES-E, RHITES-EC, DFID, USAID/PMI, CDC, IDRC, Vector Link Project, TASO and Pilgrim Africa Project, CHAI, The Ministry of Health would like to thank all the staff of the NMCP led by the Programme Manager Dr. Jimmy Opigo along with Dr. Damian Rutazaana, Dr. Daniel Kyabayinze, Dr. Catherine Maiteki -Sebuguzi, Bosco Agaba, Rukia Nakamatte, Peter Mbabazi, Dr. Jane Nabakooza, Miti Joel, Charles Ntege, and the WHO staff: Dr. Bayo Fatunmbi, Dr. Charles Katureebe, and Mr. Paul Mbaka who supported the development, review and finalisation of the Malaria Annual Report 2017/2018. It is my conviction that this report will provide information for redirecting our malaria control efforts towards malaria elimination in the coming years to accelerate progress towards a malaria-free Uganda. Thank you all Dr. Diana K. Atwine Permanent Secretary iv

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6 Preface The Ministry of Health is fast tracking efforts to reduce the burden of malaria to contribute to the wellbeing and national development of the country. Heavy investments have been made in procurement and distribution of Long-lasting nets and antimalarial medicines and diagnostics during the past years. The different health system, cultural, and socioeconomic contexts of the districts and heterogeneity of malaria in the country makes the effect of these interventions to vary. It is thus worthwhile, to know the progress over the past year at district and regional Level. In Uganda conducted a mid-term review of the Uganda Malaria Reduction Strategic Plan (UMRSP), Following this review the National Malaria Control Program and stakeholders adopted a new framework to accelerate malaria reduction efforts towards pre-elimination state dubbed the Mass Action Against Malaria (MAAM) to increase ownership of malaria control efforts by all stakeholders. To do this, continuous review of progress towards the UMRSP targets is vital. The Malaria Annual Report 2017/2018 offers the Ministry of Health and it s implementing Partners an opportunity to reflect on the activities implemented and their results in last financial year and see how best and innovatively they can be deployed in an effective, efficient and sustainable manner. I request all malaria stakeholders to critically look at the performance of all indicators in the report and develop actions that will fast track malaria reduction efforts in the country. For God and my Country Dr. Henry G. Mwebesa, Acting Director General of Health Services Ministry of Health vi

7 List of Abbreviations ACT Artemisinin-based Combination Therapy AL Artemether- Lumefantrine ALMA African Leaders Malaria Alliance ANC Antenatal Care AMFm Affordable Medicines Facility for malaria CDC Communicable Disease Control CSO Civil Society Organization DFID Department for International Development MFP District Malaria Focal Person DHS Demographic Health Survey DHIS 2 District Health Information System 2 EPR Epidemic Preparedness and Response EIR Entomological Inoculation Rate EQA External Quality Assurance FBO Faith-Based Organization GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria GOU Government of Uganda HBMF Home-Based Management of Fever HMIS Health Management Information System HSD Health Sub-district HPAC Health Policy Advisory Committee HW Health Worker iccm Integrated Community Case Management IDSR Integrated Disease Surveillance and Response IMM Integrated Management of Malaria IPD In-patient department IPTp Intermittent Preventive Treatment in pregnancy IRS Indoor Residual Spraying ITN Insecticide Treated Net IVM Integrated Vector Management JMS Joint Medical Stores LLIN Long Lasting Insecticidal Net MAAM Mass Action Against Malaria M&E Monitoring and Evaluation vii

8 MCH MDG MIS MSP MTR MoH MoU NDP NGO NHP NMCP/D NMS NRH OPD PFP PNFP PSM QA RBM RDTs RRH SBCC TWG UMIS UMRSP UNBS UNICEF USD USAID VHT/CHW WHO Maternal and Child Health Millennium Development Goals Malaria Indicator Survey Malaria Strategic Plan Mid-Term Review Ministry of Health Memorandum of Understanding National Development Plan Non-Governmental Organization National Health Policy National Malaria Control Program/Division National Medical Stores National Referral Hospital Outpatient Department Private for Profit Private Not-for-profit Procurement and Supply Management Quality Assurance Roll Back Malaria Rapid Diagnostic Tests Regional Referral Hospital Social Behaviour Change Communication Technical Working Group Uganda Malaria Indicator Survey Uganda Malaria Reduction Strategic Plan Uganda National Bureau of Standards United Nations Children s Fund United States Dollars United States Agency for International Development Village Health Team/Community health worker World Health Organization viii

9 Table of Contents Acknowledgement... iv PREFACE... vi List of Abbreviations... vii Table of Figures...x Definition of terms... xi Executive Summary... xii 1. Introduction Current situation of malaria in Uganda Progress towards malaria burden-reduction targets Impact on malaria incidence and mortality Implementation of intervention Integrated Vector management Case Management Behaviour change Communication BCC Programme Management Surveillance Monitoring and Evaluation Challenges and lesson learnt Status of malaria epidemics in Uganda Conclusions and Recommendations...33 ANNEX 1: Special Projects...35 ANNEX 2: Uganda district profiles...37 ANNEX 3: District Malaria Profiles...52 ix

10 Table of Figures Figure 1: Key Indicator scores... xiii Figure 3: Graph showing Malaria mortality for the 3 years Figure 4 : Graph showing changes in Key Malaria Impact Indicator stratified for region in Uganda...3 Figure 5: Trends in Malaria Incidence Rate...4 Figure 6 : Malaria Incidence Rate...4 Figure 7 : Key Malaria Impact Indicator by region...5 Figure 8: Test positivity rate Figure 9: Map showing Trends in Malaria test Positivity Rate in the last 3 reporting periods...6 Figure 10: Changes in Key Malaria Test Positivity Rates (Impact Indicator) by region between FY2015 and FY2017/ Figure 11: Graph showing Malaria as a share of OPD, IPD and Death for FY2016/17 and FY2017/ Figure 12: Graph showing number of suspected malaria tests and treated in Uganda over a period of three years Figure 13: Proportion of Suspected cases tested with diagnostic for FY 15/16-FY17/ Figure 14: Annual blood examination rate and Test positivity rate Figure 14: Malaria OPD numbers for FYs Figure 15: ACT doses distributed and consumed for the FY compared to FY Figure 16: Trend in Malaria death among inpatients...14 Figure 17: Graph showing malaria death for different age groups...14 Figure 18: Trends of Malaria case fatality in health facilities...15 Figure 19: Proportion of pregnant women attending ANC1 who have received 2 or more dozes of iptp...15 Figure 20: Preventin of Malaria in pregnancy for the past three year period FY Figure 21: Map showing where ICCM is implemented in Uganda...18 Figure 22: Summary of Health Facilities submitting monthly and weekly surveillance reports...25 Figure 23: Trends of IPT3 for the year Figure 24: Map showing the coverage / Location of sentinel surveillance sites in Uganda...27 Figure 25: Example of a Normal Channel graph at Health Facility in Kisoro district...30 x

11 Definition of terms Malaria incidence: Number of newly diagnosed malaria cases during a defined period for a specified population. Malaria Mortality rates: Number of deaths from malaria per unit of population during a defined period. Malaria prevalence: Proportion of a specified population with malaria infection at one time Transmission intensity: The frequency with which people living in an area are bitten by anopheline mosquitoes carrying human malaria sporozoites. Transmission intensity is often expressed as the annual entomological inoculation rate, which is the average number of inoculations with malaria parasites estimated to be received by one person in a given period. Because of the difficulty of measuring entomological inoculation rate, parasite rate in young children is often used as a proxy for transmission intensity. High transmission: are characterized by an annual parasite incidence of about 450 or more cases per 1000 population and a P. falciparum prevalence rate of 35%. Moderate transmission: areas have an annual parasite incidence of cases per 1000 population and a prevalence of P. falciparum/p. vivax malaria of 10 35%. Low transmission: have an annual parasite incidence of cases per 1000 population and a prevalence of P. falciparum/p. vivax of 1 10%. It should be noted that the incidence of cases or infections is a more useful measure in geographical units in which the prevalence is low, given the difficulty of measuring prevalence accurately at low levels. Very low transmission: areas have an annual parasite incidence of < 100 cases per 1000 population and a prevalence of P. falciparum/p. vivax malaria > 0 but < 1% Malaria control: Reduction of disease incidence, prevalence, morbidity or mortality to a locally acceptable level as a result of deliberate efforts. Continued interventions are required to sustain control. Malaria elimination: Interruption of local transmission (reducing the rate of malaria cases to zero) of a specified malaria parasite in a defined geographical area as a result of deliberate activities. Continued measures to prevent re-establishment of transmission are required. Malaria eradication: Permanent reduction to zero of the worldwide incidence of infection caused by human malaria parasites as a result of deliberate efforts. Once eradication has been achieved, intervention measures are no longer needed. Malaria Stratifications: Classification of geographical areas or localities according to epidemiological, entomological, ecological, social and economic determinants for the purpose of guiding malaria interventions. Population at risk: Population living in a geographical area where locally acquired malaria cases have occurred in the past 3 years. xi

12 Executive Summary Uganda is one of the ten countries in sub-saharan Africa that account for approximately 70% of global malaria cases and deaths. Uganda is a malaria endemic country with active transmission in 99% of the country. Whereas all people in Uganda are at risk of contracting malaria, children under-5 years of age and pregnant women are the most vulnerable. The 2016 UDHS estimated the prevalence of malaria by rapid diagnostic test in Uganda at 30% among children under the age of 5 years. Strengthened political commitment, financing and programmatic action are urgently needed to get malaria responses back on track towards pre-elimination by 2020 in line with the country s malaria reduction and strategic plan. The primary objective of this report is to document the current malaria situation and report on the progress in the period July 2017-June The results are based on health facility data collected through DHIS2 system as well as from program and partner activity reports and other records. The report highlights the progress or lack of in comparison with the previous year ( ), presented as percentage changes, proportions and actual numbers in graphs. The results are presented at National, Regional and District level. Malaria deaths reduced by 52% (3,503 compared to 7,298 reported death) during the reporting period. Malaria contributed 5% (n=2046) of the total deaths at health facilities down from 11% (4522) in the year The incidence of malaria reduced by 27% (191 vs 272 cases per 1000 population. However, malaria incidence in Karamoja and West Nile increased by over 30%. The five districts of Yumbe, Moyo, Adjumani, Lamwo and Namayingo reported malaria incidence greater than 450 cases per 1000 population. Test positivity rate (number positive /number tests) decreased by 10% points (from 49% FY2016/17 to 39% FY2017/18, and the proportion of malaria in the OPD decreased by 16% (from 67%-51%). IRS was conducted in 15 districts in Eastern Uganda and the mid-northern Uganda with support from DFID and USAID/PMI with Vector Link as the implementing agency. IRS in the 11 districts of midnorthern Uganda was conducted by the government of Uganda with support from by Global Fund as part of an epidemic response. Ministry of Health distributed over 26.5 million LLINs country wide through a universal campaign achieving an average operational coverage of over 95%. Through routine LLINs distribution, 1.2 million nets were given to pregnant women and children under-5 years during antenatal care and through the young child clinics. An additional 616,238 were given out through school distribution channels. Refugee populations were prioritized, and plans were made to provide 500,000 LLINs in West Nile and Bunyoro region. The program should fast track the Mass Action Against Malaria (MAAM) approach not only to sustain the gains acquired in last financial year but accelerate the path towards achievement of UMRSP targets and eventual elimination of malaria. Progress by UMRSP performance Monitoring Framework xii

13 Table 1: Summary of key malaria indicators Malaria mortality Rate Incidence of Confirmed Malaria Test positivity Rate Confirmed Malaria cases as Proportion of all OPD Malaria deaths as proportion of all deaths Deaths per pop. Confirmed Case/ 1000 pop Percent (%) Percent (%) Percent (%) Key Indicator scores Key Indicator scores Indicator Score Indicator Score Incidence % of facilities reporting Mortality RDT stock-out % test negative treated ACT Stock-out TPR TWG meeting Testing rate RBM meetings IPTp Key On Track to attaining UMRSP Target Little or no progress made Likely xiii

14 Permanent secretary of the Ministry of health with the US Global Malaria Coordinator on his visit to Uganda, 14 th May 2018, Kampala xiv

15 1. Introduction The Uganda Ministry of Health National Malaria Control Division (NMCD) is a Ministry of Health division responsible for implementing all malaria control and management efforts in Uganda. It is currently implementing a five-year strategy aimed reducing the burden of malaria in Uganda. Uganda is a malaria endemic country and the Ministry of Health estimated that there is active transmission in 99% of the country and all people in Uganda are at risk of contracting malaria. The most vulnerable group in terms of malaria in Uganda are children under-5 years of age and pregnant women being particularly at high risk. The 2014Malaria Indicator found the prevalence of malaria in Uganda to be 19% by microscopy and 30% by rapid diagnostic test among children under the age of 5 years. This was comparable to the rapid diagnostic test prevalence found in 2016 by the Uganda Demographic health survey of 30%. This report provides a summary of the progress in malaria control efforts in FY in Uganda. The report uses health facility data received by the Ministry of Health division of health information and available in its DHIS2 system as well as activity reports and other records. The report covers the period July 2017 to June 2018, although data from previous periods 2015/6 and 2016/17is used to contextualize data and for trend analyses. The primary objectives of this report are to track progress, highlight achievements and bottlenecks that need to be fixed and guide the NMCPs planning and implementation going forward. The Uganda Malaria Reduction Strategic Plan (UMRSP ) envisions a malaria free Uganda by 2030 with the following goals: The three goals set for the Uganda malaria Reduction Strategic plan (UMRSP) are; By 2020, reduce annual malaria deaths from the 2013 levels (30 per 100,000) to less than 1 death per 100,000 population, reduce malaria morbidity from 150 to 30 cases per 1,000 population By reduce malaria parasite prevalence (by microscopy) from 19% to less than 7%. In line with the UMRSP goals there are six objectives: Achieve and sustain protection of at least 85% of the population at risk through recommended malaria prevention measures (vector management); Achieve and sustain at least 90% of malaria cases in the public and private sectors and community level receive prompt treatment according to national guidelines (case management); Ensure least 85% of the population practices correct malaria prevention and management measures (IEC/BCC); The program is able to manage and coordinate multi-sectoral malaria reduction efforts at all levels (program management); All health facilities and District Health Offices report routinely and timely on malaria program performance (SME-OR) 1

16 2. Current situation of malaria in Uganda Uganda estimates that nearly all the approximately 39 million people living in Uganda were at risk of malaria infection in the FY 2017/18. The country has made significant strides in its efforts to control malaria with the number of malaria cases and deaths reported in the financial year 2017/18 reducing by 27% and 52% respectively compared to the FY 2016/ Progress towards malaria burden-reduction targets Of the 122 districts in Uganda 8 had incidence of malaria in the FY 2017/18 between 0 and 50 cases per 1000 population are classified as low endemicity while the rest are high burden districts. There were no areas in the country classified as being in elimination phase for malaria Impact on malaria incidence and mortality Malaria mortality In the FY 2017/18, 3503 malaria-related deaths were report in Uganda, a 52% reduction compared to figure reported in FY2016/17. This resulted in a reduction in the annual malaria mortality rate from 19.3 deaths per population in FY 16/17 to 9 deaths per population in FY 17/18, a 54% reduction. See Fig. 3 below. District that reported the highest malaria deaths in the period under review included; Lira, Soroti, Kyotera, Hoima, Masaka, Kabarole, Kasese and Arua. The UMRSP targets of less than one death per population is yet to be achieved. Malaria Mortality Rate Figure 2: Graph showing Malaria mortality for the 3 years Figure 4 shows reduction in malaria deaths by health region between FY16/17 and FY17/18. With exception of Kampala where there was a 46% increase in malaria related deaths, all other regions reported reductions in malaria related deaths with the largest reduction being reported in the Kigezi region. 2

17 Changes in Key Malaria Impact Indicator by region between FY2015/16 and FY2017/18 Figure 3 : Graph showing changes in Key Malaria Impact Indicator stratified for region in Uganda Malaria Incidence In the financial year 2017/18, the reported incidence of malaria was 191 case per 1000 population compared to 272 case per 1000 population in FY 2016/17. However, five district (Yumbe, Moyo, Adjumani, Lamwo and Namayingo) reported malaria incidence greater than 450 cases per 1000 population. Figure 6 gives a summary of malaria incidence. The distribution of malaria incidence by district is given in figure 5 below. We observe that while in FY 16/17 the whole mid northern part of Uganda had the highest incidence of malaria, in FY 17/18 we observe the highest incidence in parts of west Nile, and Nwoya district. It should be noted that most districts reported reduction in malaria incidence rate. 3

18 Trends in Malaria Incidence Rate FY15/16 FY16/17 FY17/18 Figure 4: Trends in Malaria Incidence Rate Compared to FY 2016/17, in FY 2017/18, the eight districts of Moyo, Yumbe, Kaabong, Kotido, Moroto, Abim and Arua, reported increase in incidence of malaria in excess of 50 cases per 1000 population. Thirteen districts also reported increase in incidence of malaria between 1 and 50 cases per 1000 population. All other district reported reduction in incidence of malaria (see Fig. 5). The UMRS target for inpatient malaria cases per population is 5 for the FY 2017/18. The reported number of inpatient malaria cases per population moved from 219 in FY16/17 to 128 in FY 2017/2018, a 42% reduction. (See fig. 6). Malaria Incidence Rate Figure 5 : Malaria Incidence Rate Figure 7 show percentage reduction in malaria incidence by health region. We observe that in West- Nile and the Karamoja region, there were reported increases in the malaria incidence rate. All other regions reported a reduction in the incidence of malaria. The Acholi and Lango regions reported the highest reductions in the incidence of malaria. 4

19 Changes in Key Malaria Impact Indicator by region between FY2015/16 and FY2017/18 Figure 6 : Key Malaria Impact Indicator by region Test positivity rate Reported Test Positivity Rate (TPR) in Uganda reduced from 49% in the FY2016/17 to 39% in FY2017/18, a 25-percentage reduction. The reported reduction in TPR was observed in all regions of the country except Karamoja. Following the 2015 malaria epidemic in northern Uganda, test positivity rate (TPR) in this area remained high than 60% for the FY 2015/16 and FY 2016/17. However, in the FY2017/18 we observed major reduction in TPR in this region. In Busoga and western Uganda, reported TPR for the FY 2017/18 mostly ranged between 30% and 50%. Test positivity rate FY2016/17 and FY2017/18 Figure 7: Test positivity rate Figure 9 below, shows district level distribution in TPR, we observe significant reductions in TPR across most districts. 5

20 Trends in Malaria test Positivity Rate FY15/16 FY16/17 FY17/18 Figure 8: Map showing Trends in Malaria test Positivity Rate in the last 3 reporting periods Figure 10 below gives a summary of changes in TPR by region. We observe that Karamoja region was the only district that reported an overall increase in TPR. The most significant reductions in TPR were observed in the Acholi and Teso regions of the country. Changes in Key Malaria Impact Indicator by region between FY2015/16 and FY2017/18 Figure 9: Changes in Key Malaria Test Positivity Rates (Impact Indicator) by region between FY2015/16 and FY2017/18 6

21 Malaria Burden to the Health System Malaria continues to contribute a significant proportion of the health facility cases and deaths in Uganda. Malaria as a share of OPD, IPD and Death for FY2016/17 and FY2017/18 Figure 10: Graph showing Malaria as a share of OPD, IPD and Death for FY2016/17 and FY2017/18 The UMRSP , FY2017/18 target for malaria deaths as a share of total deaths is 10%. Fig. 11 above gives a summary of malaria as a share of OPD and IPD cases as a share of all cause deaths. In the FY2017/18, malaria contributed 5% of the total reported deaths at health facilities across the country down from 11% in the FY 2016/17, meeting and surpassing the UMRS target for the period. In the same period, malaria share of inpatient cases reduced to 19% from 29% in FY2016/17, a 34% drop in share. Confirmed malaria contribution 20% of all OPD cases in FY 2016/17 down from 23% in FY 2017/18 (see Fig. 11) Implementation of intervention Integrated Vector management Under this strategy, the ministry of Health aims to achieve and sustaining protection of at least 85% of the country s population at risk through recommended malaria prevention measures. In Uganda, the main interventions within integrated vector management are Indoor residual spraying (IRS) and use of LLINs. By the end of 2017 the MoH had achieved over 88% coverage by LLIN through its routine distribution and an LLIN mass campaign. In the districts where distributions have taken place operational coverage was estimated to be over 98%. In Uganda, the main interventions within integrated vector management are Indoor residual spraying (IRS) and use of LLINs. During FY 2017/18, the country also implemented larval source management on a pilot basis. The distribution of LLINs is both through routine channels and LLIN mass distribution campaigns. The Abuja target for LLIN and/or IRS coverage is 60%. To have a protective effect, coverage of net ownership and use should be above 80%. However, the 2016 Uganda demographic and health survey found that in 2016, 67% of children under-5 years and 70% of pregnant women slept under an ITN and/or in a dwelling that had been sprayed in the past 6 months which is far below the recommended target. 7

22 For the FY 2017/18 the NMCP planned to spray inside houses with an effective insecticide (IRS): conduct IRS in 15 high burden districts in North and Eastern Uganda to rapidly reduce parasite burden; Achieve and sustain universal coverage with LLINs (1 net for every 2 persons in a household) through the distribution of 24 million nets; and Conduct environmental and entomological Monitoring. It also planned to update key strategies and guidelines as well as conduct training on entomological monitoring and surveillance. Indoor Residual Spraying (IRS) In the FY2017/18, the MOH with support from partners sprayed 1.3 million housing units with an efficacious insecticide called Actelic protecting 17% of Uganda s population. However, the level of protection was far below the UMRSP target for this year of at least 30% of the population protected. IRS was conducted in 15 districts in Eastern Uganda and the Lango region including the districts of; Amolator, Alebtong, Butaleja, Butebo, Dokolo, Palisa, Namutumba, Budaka, Serere, Bujiri, Kibuku, Otuke, Lira, Kaberamaido, and Tororo sprayed with Actellic 30S insecticide with support from USAID/ PMI and DFID. The MOH sprayed 1,280,593 (94.9 %) of the 1,348,862 houses found in the 15 districts, and protected 4,339,137 (96.6 percent) people out of the total population found (4,553,942). The protected population included 120,847 children under five and 886,137 pregnant women. The MOH also conducted IRS in 11 districts in northern Uganda as part of an epidemic response with support from the Global Fund. These districts included; Gulu, Nwoya, Oyam, Kole, Kitgum, Omoro, Pader, Lamwo, Agago, Amuru, Apac (Kwania) also sprayed with Actellic 30S insecticide. A total of 632,305 (90 %) of the 748,333 houses found in the 11 districts were sprayed, protecting an average of 90% of the targeted population. With support from PILGRIM, the Ministry of Health also conducted IRS on a pilot basis in the two sub-counties of Toroma and Kapujan in Katakwi districts. Spray operators for the Abt Associates-led Uganda Indoor Residual Spraying (IRS) 2 project in northern Uganda posing after training Spray operators for the Abt Associates-led Uganda Indoor Residual Spraying (IRS) 2 project triple rinse their spray pumps at the IRS soak pit after the daily spraying. Long Lasting insecticidal nets (LLINs) As reported in the Uganda Demographic and Health survey 2016, 62% of children under-5 years slept under an ITN while 64% of pregnant women slept under an ITN. During the FY 2017/18 the government of Uganda with support from partners conducted an LLIN mass campaign. Recent decreases in the incidence and test positivity rate of malaria in Uganda can be attributed largely to increased LLIN coverage following this just concluded mass campaign. 8

23 In the FY 2017/18, the MOH distributed over 26.5 million country wide. The goal of the UCC was to improve access to LLINs in the population. Preliminary results from this exercise show high coverage rates of over 95% all districts. The MOH also continued to provide LLINs through routine distribution channels (ANC/EPI). A total of 1.2 million nets were distributed pregnant women and children under-5 years through health facilities. Following the development and subsequent approval of the school nets distribution guidelines in the FY 2017/18, The Ministry of Health with support from PMI/USAID/MAPD conducted a large scale School LLIN Distribution pilot to explore this additional routine channel to sustain the LLIN coverage post mass campaign. In May/June, the MOH distributed LLINs through public primary schools in 22 districts in 5 regions in Uganda namely: Hoima, Rwenzori, Kampala (Central 2), Masaka (Central 1), and West Nile regions. A total of 640,569 Primary one and Primary four pupils from 2727 schools were registered to receive LLINs. A total of 616,238 LLINs were distributed to registered students achieving coverage of 96% of the targeted population. President of the republic of Uganda, YK Museveni at the closeout ceremony of the 2017/18 LLIN Mass Campaign exercise in Sheema District Following the development subsequent approval of the school nets distribution guidelines in the FY 2017/18, the Ministry of Health plans to start distribution of nets through this channel in the FY 2018/19. Refugee LLINs distributions: A total of 535,626 LLINs were secured with support from the global fund. Pre-distribution activities such as mobilization and pre-positioning were initiated. Actual distribution of the LLIN is planned to start in July Larval source Management In the FY 2017/18, all larval source management activities were implemented on a pilot basis. Three sites in three districts (Wakiso, Nakasongola and Nakaseke) were reached with this intervention using different chemicals at each of the three sites for comparison. By the end of the year, this pilot was still on going and the results are yet to be published. Entomological monitoring and surveillance The Ministry of Health in collaboration with the PMI VectorLink Project Uganda conducts routine entomological monitoring in selected sites to provide data for decision-making. Data generated is used to justify decisions such as the type of insecticide to be used and selection of target areas for IRS. It also helps to assess the quality and impact of the vector control intervention. Tests conducted during the FY 2017/18 included the following: 9

24 IRS quality assurance and insecticide decay rate monitoring in one sentinel site in each of the current 15 IRS districts. Bionomics studies to assess vector density, species composition and behaviour in five selected sites in eastern and northern Uganda Bugiri, Otuke, Tororo, Apac and Soroti Pre-IRS pyrethrum spray catches (PSCs) to assess indoor resting vector density and species composition prior to IRS and post-irs PSCs to assess outcomesof IRS in one selected site in each IRS district in eastern and northern Uganda Insecticide resistance monitoring in 4 sentinel sites of Bugiri, Lira, Gulu and Soroti. The results of these studies will be shared in the next reporting period. Capacity Building The Ministry of Health NMCD with support from the DFID/UNICEF/WHO Capacity Development grant and in partnership with the MOH Vector Control Division and malaria development partners built capacity of Vector Control Officers and other staff at the Sub National level to conduct entomological surveillance, monitoring and on use of entomological data for decision making. Entomological training was conducted in 23 districts reaching 35 Vector control officers. Training was conducted in November 2017 in the Acholi/Lango Sub regions and in March 2018 in South Western region in response to the malaria epidemics in those regions. As part of the IRS implementation in both the I5 Eastern and Northern Uganda IRS districts and the 11 Northern Uganda epidemic districts, a series of trainings employing the cascade model were conducted. Training sessions for master trainers aimed at enhancing IRS managers skills to implement and supervise IRS operations, and to strengthen their training and coaching capabilities. Comprehensive IRS trainings with a focus on practical training to enhance spraying techniques were conducted. Cadres of staff trained included: MOH staff, district Malaria Focal persons, Vector Control Officers, Information, Education and Communication (IEC) Officers, Environmental Health Officers, District Biostatisticians, District Supply Officers, subcounty supervisors, parish store keepers, team leaders and parish supervisors. Similarily, prior to LLIN distributions UCC and School distribution comprehensive trainings were conducted for staff managing operations at National, Subnational levels and the community/schools using approved training guidelines. Policies and guidelines In the FY 2017/18 the Ministry of Health National Malaria Control Division, through the IVM Thematic working group and with support from malaria development partners developed policy documents and guidelines to streamline vector control and insecticide resistance management in Uganda. Documents developed, approved and printed include the following Integrated Vector Management Strategy for Malaria Reduction in Uganda, February 2017 Integrated Vector Management Implementation Guidelines for Uganda, February 2017 Insecticide Resistance Management Plan for malaria vectors in Uganda, May 2017 School-based long-lasting insecticidal nets distribution guidelines, January 2018 In the FY 2018/19 the NMCD and malaria development partners will disseminate, distribute and operationalize the policy guidelines developed. 10

25 Case Management This strategic objective aims to ensure that at least 90% of all malaria cases in the public and private sectors as well as in the community receive prompt diagnosis and treatment according to the national malaria policy. In FY 2017/18, the NMCP planned the following activities: 1) Strengthen health worker capacities for correct management of malaria through trainings and support supervision of health workers in IMM and clinical audits; Conduct clinical audits in selected health facilities; 2) Strengthen the quality assurance and quality control of malaria parasitological diagnosis element by updating and disseminating the parasite-based diagnosis guidelines; and 3) Ensure availability of Quality Assured Anti-malarial medicines. While improvements have been observed, there continues to be challenges with testing all fever cases, treating all malaria test positives, treating test negatives, among others. (see figure 12 below). Malaria Testing rate, % test negative treated, and not tested cases treated Figure 11: Graph showing number of suspected malaria tests and treated in Uganda over a period of three years Parasitological confirmation of suspected cases Uganda is currently implemented the Test-Treat-Track policy. In line with this policy, is the provision of treatment only after a confirmed diagnosis of malaria, implying that all individuals suspected of having malaria must have a parasitological test. According to WHO, confirmation of suspected malaria cases is critical in not only in ensuring that the correct treatment is prescribed but also in ensuring accurate quantification and mapping of malaria incidence and the spatial distribution of malaria cases. The UMRSP target for the percentage of suspected malaria cases that had a parasitological test for the FY2017/18 is 80%. 11

26 Malaria Testing rate Figure 12: Proportion of Suspected cases tested with diagnostic for FY 15/16-FY17/18 The testing rate and Annual Blood Examination rate decreased as a hitch in RDT supplies was experienced in the last two quarters of the financial year. The non-tested treated decreased by 60%. However, the test negatives treated increased by 18%. Annual blood examination rate and Test positivity rate Figure 13: Annual blood examination rate and Test positivity rate Treatment of uncomplicated malaria In the FY 2017/18, there were 20 doses of ACT were distributed for malaria treatment down from 31.7 million in FY16/17, a 37% reduction. About half of all OPD cases were due to malaria in FY17/18 down from 67% in FY16/17 representing a 24% decrease. During the FY 2017/18, 32% of the malaria cases were clinical diagnosis compared to the UMRSP for the financial of 25% target. 12

27 Malaria OPD cases Figure 14: Malaria OPD numbers for FYs This reduction in cases led to a reduction in ACTs consumed by almost 9.5 million doses in this financial year compared to last year resulting in overstock of malaria commodities in many facilities. ACT doses Distributed and Consumed Figure 15: ACT doses distributed and consumed for the FY compared to FY Treatment of severe malaria Similar to the observed reduction in the reported number of outpatient malaria cases between FY2016/17 and FY2017/18, there was a reduction in the reported number of inpatient malaria cases and malaria deaths. The reported number of inpatient malaria cases reduced from about in FY 2016/17 to just over in the FY 2017/18 representing 40% reduction.. The number of deaths reduced from 7260 in the FY2016/17 to 3503 (see Fig.15). 13

28 Malaria IPD cases and deaths Figure 16: Trend in Malaria death among inpatients A breakdown of the reported number of malaria deaths shows similar trends in the number of reported deaths among children Under-5 years of age and pregnant women. In the FY2017/18, malaria deaths in children under 5 years reduced to 2046 from 4522 in FY2016/17 and 5014 in FY 2015/16. Among pregnant women malaria related deaths reduced from 426 in FY2015/16 to 274 in FY 2016/17 and finally 179 in the FY 2017/18. As observed earlier, a consistent supply of anti-malarial medicines, improvements in confirmation of malaria among other recently scaled up interventions were critical in ensuring this marked reduction in malaria deaths. Malaria mortality Figure 17: Graph showing malaria death for different age groups 14

29 The Ministry of Health continues to provide quality service to inpatient malaria cases with minimal case fatality rate reported in the last three financial years. Since the FY 2015/16 reported case fatality rate has remained below one percent. Case fatality rate in the Fy2017/18 was 0.7% a slight reduction from the 0.9% reported in FY2015/16 and FY2016/17 (see Fig. 18 below). Trends in case fatality rate Figure 18: Trends of Malaria case fatality in health facilities Prevention and Management of Malaria in Pregnancy The malaria in pregnancy policy guidelines implies a 3-pronged approach: 1. All pregnant women should access intermittent presumptive treatment (IPTp), 2. Use LLINs and 3. Access to appropriate treatment of a pregnant malaria case. The Uganda Malaria reduction strategy target states that by the Fy2017/18, 79% of pregnant women attending ANC 1 receiving one or more doses of IPTp. However, the reported proportion of pregnant women attending ANC-1 receiving one or more doses of IPTp in the FY 2017/18 was 68%, a slight increase from 57% in the FY 2016/17 representing a 20% overall increase (see Fig 19 below). Proportion of pregnant women attending ANC1 who have received 2 or more dozes of iptp Figure 19: Proportion of pregnant women attending ANC1 who have received 2 or more dozes of iptp The Ministry of Health guidelines require that LLIN should be distributed to pregnant women during their ANC-1. It is therefore important that pregnant women attend their ANC-1 visit during the first trimester of pregnancy to ensure that protection with ITNs is as early as possible. 15

30 Prevention of Malria in Pregnancy (MiP) Figure 20: Preventin of Malaria in pregnancy for the past three year period FY During the FY2017, there 1.7 million pregnant women attending ANC-1 of these, 19% of the pregnant women who attended ANC-1 did so in their first trimester of pregnancy. Attendance of ANC-1 in the first trimester has remained constant in the last three financial years. See Figure 20 above. While the number of women attending ANC-1 has increased in each Financial Year since FY 2015/16, the number and proportion of women receiving LLIN has reduced. In the FY2017/18, the proportion of pregnant women receiving LLIN was 50% down from 58% in FY 2016/17 and 71% in FY 2015/16. See figure above. In the FY2017/18, 1.4 million pregnant women received IPTp1 and 1.2 million pregnant women received IPT2. In the FY 2017/18, there were OPD malaria in pregnancy cases down from in the FY 2016/17. The IPD malaria in pregnancy cases reduced from cases in FY 2016/17 to FY 2017/18. See Figure below. 16

31 Trends in MiP OPD, IPD Integrated Community Case Management - iccm In the FY2017/18, the Ministry of Health conducted iccm in 96 districts with 70 districts covered by the public sector and the remaining 26 private sector. The two sectors implementing iccm current do it differently. While the public sector implementing partners (UNICEF, TASO, Malaria Consortium, Save the Children) cover whole districts, the coverage of private sector is partial and majorly in towns. The partners supporting iccm in the private sector include; CHAI, World Vision, BRAC, Living Goods, Plan International, Children Investment Fund Foundation and Mbarara University of Science and Technology. 17

32 ICCM coverage in Uganda Source: Figure 21: Map showing where ICCM is implemented in Uganda Capacity Building There were several supportive supervision visits to the health facilities, integrated malaria management (IMM) trainings and Clinical Audits conducted as means of capacity building. The NMCP with support from partners conducted intergretaed management of malaria (IMM) trainings in 34 out the targeted 46 districts. The training reached 625 health workers from 673 health facilities. It also conducted iccm support supervision and monitoring in 26 districts, trained VHTs and harmonized the ICCM reporting tools for VHTs with support MoH division of health information. The programme conducted a training of 9/12 ToTs on clinical audits and conducted clinical audits at 111 health facilities in 17 districts. It also trained 1,646 health workers in integrated management of childhood illnesses including malaria. The programme finalized the IMM training manual for the private sector. It also finalised and disseminated the IPTp guidelines to selected districts and stakeholders (details in the MIP section). During the year, the NMCP conducted training for 302 out of the target 800 health workers use of RDT for testing. External Quality Assessment guidelines and the QA/QC manual were finalised and printed. The programme also initiated the process for establishing a malaria reference laboratory for Uganda. External quality assurance for diagnostics (Blood slides and RDTs) was conducted along with laboratory mentorship in 8/20 targeted laboratories in the country. 18

33 Table 2: Details of Health worker in IMM and VHTs trained Implementing Partner No of H/W trained in IMCI No of VHT trained No of facilities attached to VHTs UNICEF 14, No of villages receiving iccm SCI Malaria Consortium , ,276 GF PACE 538 6, ,551 GF PILGRIM 216 3, ,731 GF UHMG 328 6, ,744 IRC 42 2, MUST TOTAL 1,646 47, Development of Policies, guidelines and SoPs - The Malaria Policy was updated to incorporate IPT3. (Mothers must have a minimum of 3 doses of Intermittent Presumptive treatment). - The iccm guidelines have been updated to add a community supply chain management to improve management and accountability of commodities at the community level - The following malaria diagnostics guidelines where finalised and printed: o National Quality Assurance: Guidelines for Malaria Diagnostics 2017 o Training Guidelines for Malaria Diagnosis 2007 o Implementation guidelines for Malaria parasite-based diagnosis in Uganda Behaviour change Communication BCC Through this strategy, the NMCP aims at having at least 85% of the population practicing correct malaria prevention and management measures. The 2016 UDHS found that 80.7% of children with fever sought treatment for fever. The survey also found that over 90% of the Uganda population have knowledge on malaria and its prevention. However, while knowledge is high, recommended practice and behaviour remains low in most of the country. As Ministry of Health, there is needs to quickly bridge the knowledge-practice gap, by: - Patients seek treatment within 24 hours of onset of symptoms - Clients demand for testing before treatment and that medical staff adherence to test results - All people consistently use LLINs every night to prevent malaria; - House hold heads engage in environmental management around home steads; - Communities embrace indoor residual spraying and larval source management. The plan for FY 2017/18 under this strategy was to: 1) Strengthen the implementation of the national communication framework through supporting quarterly coordination meetings at the regional level; 2) disseminate key messages on malaria prevention and management; strengthen the capacity of VHTs to undertake BCC activities; as well as commemorate key malaria events. 19

34 Coordination During the period under review, the Ministry of Health and her partners held four Technical Working Group meetings to strategize and coordinate the implementation of BCC activities under taken by the Ministry of Health and her partners. Through these meeting, key messages on malaria were developed and/ harmonized before dissemination throughout the country. Advocacy In the FY under review, the national malaria control programme held a launch for the Parliamentary Forum on Malaria as well for the MAAM initiative. During this launch, His Excellency the president of Uganda YK Museveni was the guest of honour. The Ministry also reached-out for the purpose of their participation in the fight against malaria to religious and cultural leader. The Ministry of Health held advocacy meeting with the ministry of education. Social/community Mobilization During the just concluded LLIN mass campaign in the country, the BCC unit of the national malaria control programme with support from partners engaged in community mobilization across the country reaching about 78% of the country with messages on net registration, distribution and use. Interpersonal communication engagement During the FY2017/18, the Ministry of Health in a bid to reach out to communities with limited access to TV and Radio, intensified Inter personal Communication through a number of activities. The Ministry of Health with support from partners conducted orientation for VHTs, as well as Religious, Opinion and Cultural leaders on community dialogues for action using local existing resources within the community. Consequently, these teams have been influential in sensitizing the communities on Malaria prevention measures. Relatedly, Village Malaria prevention/health Club were formed in a number of districts with support from MAPD. Additionally, Orientation in inter personal communication was conducted for health workers, Champions and Head teachers in 46 districts. The Ministry of Health also conducted Home-Visits to further diffuse undesired behaviour patterns.this helped to strengthen community initiatives for change. With support from MAPD, MoH placed 38 TV screens outpatient departments at selected health Facility as a way to engage patient with correct messages while they await service at health facilities. This has helped to create awareness and trigger patient-health work dialogue as clients may ask questions for clarifications. As part of Mass action against Malaria (MAAM) implementation, the Ministry of Health also supported the establishment of Malaria clubs in schools with an objective of using pupils as malaria champions and change agents. School activations through Music Dance Drama (MDD), school debates/quizzes, branded sports completions and orientation of Teachers were also with support from partners. Development of IEC materials During the implementation period, working with partners, the program developed and disseminated 36 Information, Education and Communication messages for all the Malaria intervention areas. The development of the malaria messages was based on results of knowledge Attides and Practice (KAP) studies conducted by the Communication for Healthy Communities. Print Media: The Ministry of Health developed; LLIN brochures, LLIN Frequently Asked Questions, LLIN Posters, LLIN T-shirts, LLIN Banners and Talking points for the Clergy for the LLIN mass campaign. 20

35 It also developed; counselling guide for VHTs and Health providers, Talking points Malaria Champions and Posters with support from Communication for Healthy Communities. The ministry also engaged in development of MPI-posters and Talking Points for health providers with support from MAPD. Broadcast Media: The Ministry of Health conducted seven Mass media campaigns throughout the Country with support from Partners. The campaigns largely focused on the LLIN distribution exercise and involved over 63 radio stations and five TV stations airing messages on the LLIN. The Ministry of Health launched the Live your Dream campaign with support from MAPD with a focus on Malaria in pregnancy and Net use. With support from CHC, it undertook various Mass media Obulamu campaign throughout the country. The ministry also engaged in mass media campaigns for the promotion of ACTs with a Green Leaf. The estimated reach of this campaign was 78% of the population. The messages aired during this campaign were in form of Radio/TV Spots, live announcements, Talk shows, Guest appearances and DJ Mentions. Commemoration of important days During the year, the programme organised the 13 th world malaria day commemoration celebrations celebrated which took place in Mpigi district with over 1,000 people in attendance. During the occasion, key advocacy concerns on malaria were raised especially on the promotion of the use of mosquito nets and the need to scale up the use of Indoor Residue Spraying. The theme of the day was End malaria for good and the slogan was children against malaria. The occasion was graced by Hon. Sarah Opendi, the state minister for health as the guest of honour. In her speech, she urged Ugandans to always test before treating for malaria and encouraged the proper use of LLINs. The minister was joined by 11 members of the Uganda Parliamentary forum for Malaria at the celebration field in Mpigi districts. Committing to malaria control at the World Malaria day 24 th April 2018 in Mpigi district 21

36 Capacity Building In FY2017/2018, the NMCP conducted orientation of VHT and community leaders on formation of malaria clubs in 46 districts. Training was also conducted for cultural leaders in 46 districts on their roles in malaria prevention and control. The programme also conducted training for key influencers to be able to conduct community dialogues and home visits to strengthen inter personal communication. The programme also conducted a training-of-trainers of health workers on inter personal communication. In the same period the NMCP trained teachers in preparation for the School net distribution campaign on malaria prevention and control as well as on development of malaria clubs and use of children as agents of change in health. This was done with the aim of creating a critical mass of school children that can be malaria agents of change. Policies, guidelines and SoPs During the reporting period, the NMCP with support from partners developed SoPs for conducting BCC related activities for the LLIN distribution among refugees, schools net distribution BCC guideline and the associated communication plan Programme Management The UMRSP aims to ensure that the programme is able to manage and coordinate a multi-sectoral malaria reduction response at all levels. In the FY 2017/18, the NMCP intended to undertake advocacy and resource as well as ensure optimal delivery of malaria control interventions through ensuring human resource capacity, compliance as well as monitoring and supervision of activity implementation. The programme also planned to ensure coordinated response of malaria control activities by all stakeholders including the private sector through national and RBM mechanisms. It also planned implement activities aimed at strengthening programm capacity for procurement and supply chain management of malaria control commodities. Coordination and Multi sector Engagement During the FY 2017/18, the programme conducted thematic working group meetings for SME-OR, Case management, and IVM. The programme conduct four RBM meetings as a coordination platform for stakeholders involved in malaria control activities. Permanent secretary Ministry of Health opening the second quarter RBM meeting at Hotel Africa April

37 The Uganda Parliamentary Forum on Malaria (UPFM) was launched on 5th April by H.E the president of Uganda, Gen. Yoweri Museveni. He pledged to support the Malaria fund and malaria elimination efforts. The Ministry of Health gave award of recognition to several persons involved in the fight against malaria in Uganda. Recipients included: Dr Talisuna Ambrose, Dr Myers Lugemwa, Dr. Sezi Charles, Dr Lois Mukwaya. Prof. Kirya George, Prof. Moses Kamya, Ms Zahara- Journalist, General Eli Tumwine, Dr Ivan Kamya for DHO leadership, Dr Nassanga Ruth for Mpigi District, Prof Kirumira on behalf of Global Fund Uganda Country Coordination Mechanism, Mr David Masiko for Against Malaria Foundation, Ms Joy Phumaphi the Executive Secretary, African Leaders Malaria Alliance (ALMA) Dr. Kasete Admasu the CEO, Roll Back Malaria Partnership, Ms Robinah Lukwago for DFID, UNICEF and Dr. Yonas Tegegn Woldemariam for WHO Uganda. The program also engaged other stakeholders such as the Ministry of Education and set up a school health task force for malaria reduction; it participated in the CHOGM malaria summit and paid a visit to the speaker of parliament of the republic of Uganda. During the reporting period, the programme initiated a partner mapping exercise aimed at developing a partner map of malaria. Partners were visited to collect information and finalization of the partner map is on-going. Resource Mobilization During this period the Ministry of Health was awarded a Global Fund Grant of $185m to combat malaria. The Ministry also received support from DFID worth $60M for Strengthening Uganda s Response in Malaria (SURMA) project that will cover 25 districts in Northern and Eastern Uganda. PMI/USAID has also agreed to support Malaria reduction efforts with a grant of $30m. During the launch of the MAAM initiative and the PFM, the president of Uganda announced the establishment of the Presidential malaria fund and the framework for its operationalization will be finalised by the NMCP in the next financial year. The programme also initiated the process of developing a resource mobilization strategy for malaria in this financial year. Procurement Supply management- PSM During the financial year under review, 24 million doses of ACTs, 3.7 million vials of Artesunate, and 27.8 million Rapid diagnostic tests were distributed to the public and private not for profit facilities. An End User Verification Survey done in July 2017 showing that 97% of the health facilities had adequate stock of anti-malaria medicines. The End User Verification Survey 6 done in 2016 had report that only 89% of the health facilities had adequate stocks of anti malarials. The Ministry of Health engaged National Medical Stores and districts during the financial year to strength evidence based PSM during the financial year under review. 23

38 Percentage of health facilities with at least one ACT on the day of the EUV Planning During the Financial Year, the NMCP together with partners developed and implemented a joint work plan. The process of development of the workplan too longer than anticipated and mechanisms have been but in place that this is done in a shorter time in the following period. Policies, guidelines and SoPs During FY17/18, the NMCP initiated the development of the LLIN repurposing guideline and the Routine LLIN distribution guideline. The programme also initiated. The NMCP also initiated the process of updating the malaria policy no align it with the new global malaria technical strategy and other malaria related developments in the country and the region. Capacity to implement During the FY, the programme conducted M&E training for NMCP staff. All NMCP staff and selected partner staff were involved in the meeting Surveillance Monitoring and Evaluation This objective aims to have all health facilities and district Health Officers reporting routinely and timely on malaria programme performance. Under this strategy in FY 2017/18, the programme planned to: 1) strengthen epidemiological, parasitological and entomological surveillance; production of quarterly surveillance bulletins; strengthen malaria surveillance through HMIS (public and community); and conduct program implementation reviews. 2) conduct regular malaria surveys/evaluations; strengthen data collection from the private sector; strengthen data demand and use at all levels; and 3) implement the operation research agenda for malaria. Reporting, Reviews and evaluations During the FY under review, the Ministry of Health with support of partners conducted a mid-term review of the Uganda Malaria Reduction Strategy ( ). The review recommended a Mass- Action-Against-Malaria as a framework for accelerating the implementation of the UMRSP. In this same year, MoH produced two Quarterly Bulletin Malaria, 51 Weekly Malaria Status reports and one malaria Executive Briefs as tools to track progress in malaria control and it shared these with relevant stakeholders. 24

39 The Ministry of Health also initiated a malaria-death audit process to as part of its efforts to achieving zero deaths due to malaria. The programme in collaboration will ALMA developed a malaria scorecard to facilitate performance monitoring and management decision making in the same period. It also as part of her international commitment, submitted Uganda data for the production of the world malaria report in the same FY. Submission of Routine data by health facilities The Ministry of Health requires all health facilities to provide weekly and monthly report of cases seen across all disease managed. While all public health facilities have been registered to report in the DHIS2, only about 25% of the privately-owned health facilities are registered in the DHIS2 for reporting. % of health facilities submitting reports Figure 22: Summary of Health Facilities submitting monthly and weekly surveillance reports Figure 22 above gives a summary of the report completion rates for OPD month reporting, IPD monthly reporting and weekly surveillance reporting. In FY 2017/18, all health facilities currently registered in the HMIS submitted their monthly OPD reports. This was up from 98% in the FY 2016/17. In the same period IPD monthly reporting rate was 97% up from 94% in the previous financial year, A slight drop in the level of weekly surveillance reporting was observed in the same period with weekly surveillance reporting rate dropping from 77% in FY 2016/17 to 75% in FY 2017/18. Since the introduction IPTp3 and its subsequently inclusion within the HMIS tools in July 2017, reporting of this data element has steadily improved. The proportion of health facilities submitting reports with data on IPTp3 increased from about 16% in July 2017 to 54% in Jun This improvement is quite remarkable and should be encouraged and strengthened. 25

40 Reporting IPT3 Figure 23: Trends of IPT3 for the year Data Quality Audits and Reviews During the FY 2017/18, the Ministry of Health conducted xx data quality reviews in which data elements relevant for malaria where included. In these reviews highlighted a number of challenges with the data. These included; Use of wrong registers and aggregate form is some health facilities Minimum review and analysis of routine data at district and facility levels Malaria Death Investigation and Audit During the FY2017/18, the Ministry of Health introduced a weekly malaria death investigation process, through this process. Through this process, the Ministry of Health has been able to confirm all malaria deaths as well as identify reasons for deaths due to malaria. Below is a summary of the attributable causes for malaria deaths during the financial year: 1) Late coming in health care facilities for medical attention coupled with delayed referral were the most predominant 2) Anemia and the shortage of blood in most facilities was commonly linked to deaths among children under five year. 3) Children under five years contributed 75% of the total malaria deaths. Sentinel surveillance In FY , the Uganda Malaria Surveillance Program (UMSP) expanded the malaria-sentinel site surveillance program from 21 to 35 outpatient health facilities located in 32 districts in the country with support from PMI/USAID/MAPD and in collaboration with IDRC.. The goal of the expansion was to enable the MoH to get high quality malaria data from a wider geographical area across the country with better epidemiological representation as it seeks to make surveillance a core intervention. 26

41 Location of sentinel surveillance sites in Uganda Figure 24: Map showing the coverage / Location of sentinel surveillance sites in Uganda Therapeutic efficacy Testing of Antimalarial medicines in Uganda: The emergence of artemisinin resistance and high treatment failure with Artemisinin- based Combination Therapy (ACT) in South East Asia call for vigilance in monitoring therapeutic efficacy of antimalarial medicines. During the FY 2017/18, The Ministry of Health conducted four preparatory meeting as part of activities intended to lead to a successful TES study in Uganda. The TES will be conducted in the FY 2018/19. Epidemic detection and Response The Ministry of Health responded to malaria epidemics in Kisoro, Nwoya and Black water fever upsurge in Manafwa. The Malaria cases in Kisoro were reduced to pre-epidemic levels. The program is currently responding to Nwoya and Manafwa epidemics. 27

42 NMCP staff collecting larva at Sereri swamp in Kisoro district as part of malaria outbreak investigation Operational Research A study on the efficacy of Piperonyl Butoxide (PBO) in malaria control was initiated during the reporting period and is currently in advance stage. The country continues to conduct entomological studies including: Insecticide susceptibility status, Insecticide resistance mechanisms, insecticide resistance intensities in 4 districts of Arua, Apac, Tororo and Kanungu. IRS Susceptibility studies and Insecticide Resistance monitoring conducted. A study supported by Pilgrim with the objective of conducting health facility surveillance and entomological monitoring as part of evaluation of effectiveness of different combinations of malaria control strategies (MDA+ with IRS, MDA+IRS+LLINs, vs IRS+LLINs vs LLINs vs LLINs) A Scientific Colloquium was conducted as part of the world malaria day celebration during the financial year where researchers from presented new evidence in the area of malaria control. Together with IDRC a malaria stakeholder s dissemination meetings was held in which several studies were discussed and shared with malaria implementing partners. Capacity Building In order to strengthen district level capacity in Surveillance, Monitoring and Evaluation- district-level capacity assessment and mentorship concept developed and rolled out in fourteen select districts. A multi-faceted approach was used to implement the activities. Strategic policies, guidelines, training circular and tools were developed to support capacity and health systems strengthening activities. A national training of trainers (ToT) for malaria surveillance was done with over 30 participants. A regional ToT was done in which 14 districts participated. In collaboration with USAID supported MAPD project, over 45 district health teams were trained in malaria data use and analysis. National ToT refresher for EPR for Malaria with CPD/WHO/DFID was done and 25 National level trainers trained. With support from CPD/WHO 529 Health Workers trained from 82 districts 10 regions venues (Jinja, Soroti, Mbale Tororo, Lira, Arua, Gulu, Hoima, Mbarara and Kabale. Training on conducting Therapeutic Efficacy studies on going. The following abstracts were submitted for scientific conferences: 1. Early detection of malaria upsurges at sub-national levels in Uganda 2. Transforming surveillance into a core intervention: The path to building a strong malaria surveillance system in Uganda 28

43 3. Malaria Death Surveillance in Uganda: Novel approach to introduce mortality Audit in high patient volume facilities 4. Early Focal Malaria Upsurge Detection and Response in Kisoro, a low transmission, unstable malaria setting of Uganda Policies, guidelines and SoPs - Epidemic Preparedness and Response guidelines update: preliminary work on going. 2.2 Challenges and lesson learnt Selection of indicators: The current selected indicators for SMEOR are inappropriate to track implementation of malaria activities. A SMEOR thematic working group is in place but needs to be regular to support the functioning of this team. There is limited retrieval and analysis of readily available data from both DHIS2 and other programs to inform implementation and decision-making 29

44 3. Status of malaria epidemics in Uganda Figure 25: Example of a Normal Channel graph at Health Facility in Kisoro district 3.1 Background The Country had malaria outbreaks in Nwoya and Kisoro. There were also increased malaria above the normal channel levels in West Nile districts of Moyo, Yumbe, Arua, Packwach, Adjumani and Maracha largely attributed to the immigration of sudanese and Congolese citizens from insecurity in these countries. Kisoro and Nwoya district health teams timely identified the epidemics and notified the national control Divisionand stakeholders. The district lead approach led to quick control of the epidemic in Kisoro. The National Malaria Control Division is focussed on empowering all districts and facilities to have capacity to detect and respond just as Kisoro did. Figure 26: Kisoro District Malaria Normal Channel 30

45 3.2 Risk factors and drivers of the malaria epidemics Following outbreak investigation in the affected districts, a number of risk factors for the detected epidemics were identified; Human Activities- The encroachment of the swamps by human activities such as brick making, farming and mining have created several breeding areas for mosquitoes such as the case of the outbreak in Kisoro Scale down of interventions as was the case in Northern Uganda leaves a population with low immunity and at risk of not only malaria but also severe forms of the diseases Weak Health systems leaving many populations without access to vital interventions such as malaria case management leading to delayed health care seeking habits Weak surveillance systems make it hard to detect epidemics and respond to them on a timely basis Climate and environmental factors such as global warming have made areas initially with low mosquito density such as Kigezi to have increased populations. The Increased rainfall pattern in some seasons predisposes ill prepared districts to upsurges. 3.3 Best practices in epidemic detection and response Community outreaches in malaria hotspots with screening and treatment to supplement facilities drastically reduces cases like in Kisoro Involvement of the district and local leadership in malaria epidemic control immensely improves on uptake of interventions such as net use Nwoya and Kisoro district were able to construct normal channels and identify the malaria epidemics within 3 weeks of onset Kisoro district leadership investigated, confirmed and responded to the epidemic using available district resources such as redistribution of staff from low malaria burden to high burden areas as they waited for MOH support. 3.4 Main Challenges A resurgence of malaria after cessation of interventions. This is critical in resource limited settings like Uganda. As part of the epidemic response in Northern Uganda, all 11 districts received one round of IRS with Actellic. However, at the end of this financial year we saw a rebound of malaria in all the districts. Limited resource envelope to comprehensively respond to epidemics. The response is still piece meal because mobilizing funds for interventions such as Indoor Residual Spraying, Larviciding and Mass Drug administration is a very arduous task at district and National level The reduction of malaria prevalence predisposes the population to severe forms of malaria due to low immunity. This was the case of the outbreak of Black Water fever in Manafwa. Severe malaria is big challenge to our weak health system. A number of communities do not have good coverage of the health system such as Karamoja and highland areas. The surveillance system for the private sector and community is still weak. This means outbreaks are sometimes detected late The unstable political environment of neighbouring countries leading to mass influx of refugees and populations along borders that are not having access to malaria interventions. 31

46 3.5 Recommendations to strengthen epidemic preparedness and response Strengthen malaria data use for action at facility and district level by all stakeholders Advocacy and mobilisation of resources for f contingency funds at district and National level for epidemic response. Scale up and Fast track implementation of interventions of malaria reduction for eventual elimination Strengthening iccm and increased investment in facilities and health system building blocks to cover vulnerable populations. Development of a holistic private sector and community strategy to strengthen surveillance and response. 32

47 4. Conclusions and Recommendations 4.1 Conclusions There has been a significant decline in the malaria mortality and mobility in the FY compare to the previous year. The decline in morbidity however was not observed in West Nile and Karamoja regions and the plausible factor being influx of migrant population and limited use of interventions. A universal net coverage campaign was conducted in Uganda and one round of IRS conducted in the 11 Northern Uganda (Acholi) regions, to manage the malaria resurgence that followed withdrawal of the intervention. There was increased availability of malaria case management commodities especially in the public sector, improved coordination between Ministry of Health, National medical stores, districts and health facilities. However, with improving stock management, there is need for more granular planning and tracking of stock at district level for efficient internal redistribution of the medicine at that level. There were capacity building activities including trainings in Surveillance, epidemic preparedness and response and case management in over 80% of the districts. Community interventions including ICCM roll out and provision of tools were continued at various sites. There is limited mechanism for enforcing adherence to prevention and treatment guidelines by health workers especially at the lower facilities. Continued capacity building including clinical audits and case management will be needed to improve outcomes. Partner Coordination and collaborations was strengthened through technical working groups and meetings. A mid-term review of the UMSRP was conducted and provided key recommendations that directed the ministry to accelerate the interventions if they are to achieve the 2021 targets. 4.2 Recommendations Sustain the gains in the reduction in mortality and morbidity achieved over the past year, the following are recommended o The malaria stakeholders take up the UMRSP mid-term review recommendations including review of policies and guidelines o Provide at least two rounds of IRS in Northern Uganda as we plan the exit strategy o Fast track the malaria fund announced by H.E the President o Utilise the lessons learnt from the LLINs to plan the next Universal Coverage campaign for LLINs in Uganda o Strengthen the PSM to adequately manage the over stock and prevent expiry of commodities in all districts o Close support to district during planning and implementation to increase ownership and governance oversight To sustain the gains in reducing malaria mortality, MOH and partners should promote integrated program approach and strengthen health care delivery system to ensure at all levels: prompt diagnosis, appropriate treatment, tracking and timely referral as and when required. Based on the observed impact of IRS in Northern Uganda, MoH and partners should prioritize IRS in hot spot districts while rolling out across a wider geographic coverage. 33

48 NMCP should urgently develop and implement a plan for mass action against malaria using and engage multi-sectoral approach at individual, household, community, district, institutional, national and international level; to create a mass movement against malaria in line with the framework for malaria smart families and communities, for zero malaria death by 2020 and a malaria free Uganda by Among others, the following initiatives should be prioritized: a) Mass Action Against Malaria; and b) Uganda Parliamentary Forum for Malaria (UPFM)- a community that serves as advocates for political, legislative and community action for a malaria free Uganda. NMCP should operationalization of the intended decentralized service delivery at district level. Touchdown model to decentralize National Malaria Control Program to the District levels towards reaching every household should be operationalized. Staff of NMCD will be assigned to empower and coordinate malaria action in clusters of districts in the 14 Uganda regions, in line with Regional Referral Hospital catchment areas. NMCD needs to improve and strengthen coordination with the private sector quality of care provided, training in IMM and provision of tools to enhance data collection and reporting into DHIS Way forward All malaria stakeholders must play their part not only to sustain the gains but to accelerate the path towards achieving malaria free Uganda. This process has been embedded in the new strategy of Mass Action against Malaria (MAAM). This requires commitment and dedication not only from Ministry of Health but from global partners, in country organisations, politicians, opinion leaders, district and community members. There is need to increased coordination and information sharing between all malaria implementing partners to promote the three ones : One Coordination, One plan, and M&E 34

49 ANNEX 1: Special Projects MAPD USAID s Malaria Action Program for Districts (here in referred to as MAPD) through President s Malaria Initiative (PMI) funding aims to improve the health status of the Ugandan population by reducing childhood and maternal morbidity and mortality due to malaria. This project is implemented by Malaria Consortium in partnership with Jhpiego, Banyan Global, Communication for Development Foundation Uganda (CDFU), Deloitte Uganda, Infectious Diseases Institute (IDI) and International Development Research Collaboration (IDRC). The 5-year project supports the Government of Uganda in reducing deaths from malaria among the general population, especially children under five years of age and pregnant women, with a geographical focus of 47 districts. RHITES SOUTH WEST Covers 16 districts of the South-West region: Kisoro, Kanungu, Rukungiri, Kabale, Ntungamo, Ibanda, Isingiro, Kiruhura, Bushenyi, Sheema, Buhweju, Mitooma, Rukiga, Rubanda, Rubirizi & Mbarara Malaria. Covering. Covering training, motorship, provision of job aids, data reviews, regional stakeholders meetings. CDP Support to the NMCP Capacity Building for effective delivery of the Uganda Malaria Reduction Strategy (UMRSP). The project intends to do this by: Strengthen human resources capacity of NMCP; Strengthen the planning, programming, supervision, monitoring and evaluation in respect of malaria service delivery; and To improve the coordination and implementation of malaria control activities at national and sub-national levels Uganda IRS project Conducts IRS and entomological monitoring in 14 districts in Eastern and north eastern Uganda. The project also conducts capacity building activities across the country. PILGRIM Involved in trial of Enhanced suppression of malaria transmission with joint medical and entomological control measures: operational research in Uganda. Working in collaboration with Rotary International, IDRC, Uganda IRS, Peace Corps Uganda, Makerere University School of Public Health, Rotarian Malaria Partners, Rotary Districts 5020, 5030, and 9211, Bill & Melinda Gates Foundation. IDRC Supported sentinel surveillance in 35 malaria reference districts located in districts. IDRC also supports studies in malaria including drug efficacy studies of first and second line antimalarial. IDRC is also involved in the evaluation of the process, outcome, and impact of Global fund activities. 35

50 TASO The activities TASO is implementing Global funded activities that include: community interventions that include; Integrated Community Case Management (ICCM) targeting children under 5yeras; trainings of cadres at different levels to ensure quality ICCM service delivery, training of private for profit (PFP) sector in the Integrated Management of Malaria and routine HMIS reporting, support supervision activities together with technical teams from the district to PFP Health facilities and facilities implementing ICCM in 29 districts, Provision of routine Long Lasting Insecticidal Treated Nets (LLINs) in ANCs (Antenatal Clinics) and EPI (Expanded Programme for Immunization) clinics for PNFP (Private not for Profit) and Public health facilities and various SBCC (Social and Behavioral Change Communication) interventions including school engagement activities with the Ministry of Education and Sports. ICCM implementation is now in 29 districts in the Eastern (5), West Nile (6), Western (6), Central and Southern (12) regions of the country. RHITES E The USAID-funded Regional Health Integration to Enhance Services in Eastern Uganda (RHITES-E) Activity is USAID-funded activity supporting the Government of Uganda (GOU) and key stakeholders to increase availability and utilization of high quality health services in 23 districts in Eastern Uganda and 2 in Karamoja region. RHITES-E worked with districts to improve and strengthen knowledge and skills of health workers in various health service areas through classroom based training and facility based mentorship. 318 health workers were trained on integrated management of malaria, 230 on quality assurance for mrdts, and 678 were mentored on new guidelines for management of malaria in pregnancy including IPTp. Mentors observed improvements in implementation of the IPTp3+ strategy across all districts with data being captured in the ANC registers. On site mentorship for 1906 HWs on the test and treat policy and quality assurance on mrdt use at facilities contributed to an increase in the proportion of patients treated after a positive laboratory test 36

51 ANNEX 2: Uganda district profiles Acholi Burden OPD case Confirmed IPD cases Under 5 Pregnant Women 668, ,657 30, ,768 17,898 Coverage Testing rate: 69%, % Negative treated: 34%, % Positive treated 97% IPT2 Coverage: 79% IRS: Yes iccm: Yes Impact Trends in Death Trends in Incidence 37

52 Ankole Burden OPD case Confirmed IPD cases Under 5 Pregnant Women 554, ,686 22,989 78,901 7,738 Coverage Testing rate: 48%, % Negative treated: 24%, % Positive treated 100% IPT2 Coverage: 77% IRS: No iccm: Yes (5 districts) Impact Trends in Death Trends in Incidence 38

53 Bugisu Burden OPD case Confirmed IPD cases Under 5 Pregnant Women 444, ,125 23,437 88,667 8,075 Coverage Testing rate: 46%, % Negative treated: 41%, % Positive treated 100% IPT2 Coverage:70% IRS: No iccm: No Impact Trends in Death Trends in Incidence 39

54 Bukedi Burden OPD case Confirmed IPD cases Under 5 Pregnant Women 492, ,365 18, ,964 6,959 Coverage Testing rate: 38%, % Negative treated: 33%, % Positive treated 100% IPT2 Coverage: 83% IRS: Yes iccm: No Impact Trends in Death Trends in Incidence 40

55 Bunyoro Burden OPD case Confirmed IPD cases Under 5 Pregnant Women 542, ,337 29, ,898 14,585 Coverage Testing rate: 80%, % Negative treated: 19%, % Positive treated 100% IPT2 Coverage: 60% IRS: No iccm: Yes (2 districts public) Impact Trends in Death Trends in Incidence 41

56 Busoga Burden OPD case Confirmed IPD cases Under 5 Pregnant Women 1,490, ,218 40, ,689 36,877 Coverage Testing rate: 74%, % Negative treated: 54%, % Positive treated 90% IPT2 Coverage: 64% IRS: No iccm: No Impact Trends in Death Trends in Incidence 42

57 Kampala Burden OPD case Confirmed IPD cases Under 5 Pregnant Women 377, ,567 5, ,918 5,158 Coverage Testing rate: 49%, % Negative treated: 40%, % Positive treated 78% IPT2 Coverage: 33% IRS: No iccm: No Impact Trends in Death Trends in Incidence 43

58 Karamoja Burden OPD case Confirmed IPD cases Under 5 Pregnant Women 498, ,377 41, ,239 11,012 Coverage Testing rate: 36%, % Negative treated: 82%, % Positive treated 91% IPT2 Coverage: 77% IRS: No iccm: Yes (All districts) Impact Trends in Death Trends in incidence 44

59 Kigezi Burden OPD case Confirmed IPD cases Under 5 Pregnant Women 172, ,996 11,833 27,618 1,162 Coverage Testing rate: 77%, % Negative treated: 20%, % Positive treated 69% IPT2 Coverage: 91% IRS: No iccm: No Impact Trends in Death Trends in incidence 45

60 Lango Burden OPD case Confirmed IPD cases Under 5 Pregnant Women 380, ,067 18,191 85,580 16,832 Coverage Testing rate: 34%, % Negative treated: 36%, % Positive treated 100% IPT2 Coverage: 75% IRS: Yes iccm: Yes (3 districts) Impact Trends in Death Trends in incidence 46

61 North Buganda Burden OPD case Confirmed IPD cases Under 5 Pregnant Women 1,009, ,243 27, ,700 20,483 Coverage Testing rate: 60%, % Negative treated: 32%, % Positive treated 100% IPT2 Coverage: 63% IRS: No iccm: Yes (3 districts) Impact Trends in Death Trends in incidence 47

62 South Buganda Burden OPD case (define) Confirmed IPD cases Under 5 Pregnant Women 989, ,532 45, ,784 15,003 Coverage Testing rate: 60% (ABER), (trend); TPR % Negative treated: 29%, % Positive treated 83% IPT2 Coverage: 62% (trend) IRS: No iccm: Yes (10 districts) Impact Trends in Death (number/100,000 pop) Trends in incidence (number/1000 pop) 48

63 Teso Burden OPD case Confirmed IPD cases Under 5 Pregnant Women 682, ,588 35, ,562 21,742 Coverage Testing rate: 28%, % Negative treated: 47%, % Positive treated 83% IPT2 Coverage: 75% IRS: Yes (Pallisa, Serere, Kaberamaido) iccm: Yes (4 districts) Impact Trends in Death Trends in incidence 49

64 Tooro Burden OPD case Confirmed IPD cases Under 5 Pregnant Women 725, ,515 61, ,963 11,852 Coverage Testing rate: 81%, % Negative treated: 54%, % Positive treated 71% IPT2 Coverage: 77% IRS: No iccm: Yes (5 districts) Impact Trends in Death Trends in incidence 50

65 West Nile Burden OPD case Confirmed IPD cases Under 5 Pregnant Women 1,951,758 1,534,176 85, ,148 31,117 Coverage Testing rate: 81%, % Negative treated: 28%, % Positive treated 91% IPT2 Coverage: 75% IRS: No iccm: Yes Impact Trends in Death Trends in incidence 51