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Severe Malaria Case Management at Health Centres in Uganda

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Severe Malaria Case Management at Health Centres in Uganda Republic of Uganda, Makerere University Development Data 1 Ministry of Health, Uganda Acknowledgements This report was developed by the Ugandan National Malarial Control Programme (NMCP), Ministry of Health Uganda in partnership with Medicines for Malaria Venture (MMV), Child Health and Development Centre, Makerere University, and Development Data. The NMCP requested support from MMV for the production of a report that would provide insights on how to improve current severe malaria case management practices at level III and IV health centres in Uganda. The rapid assessment documented in this report provides a quick outline of insights on how severe malaria case management can be improved. The NMCP and MoH of Uganda has consented to place this report in the public domain via the Severe Malaria Observatory and to be shared among partners. 2 List of Acronyms ACT Artemisinin-based combination therapy AIDS Acquired immune deficiency syndrome ANC Antenatal care ART Antiretroviral therapy CRD Chronic respiratory disease DBS Dried blood spot DTP Diphtheria, Tetanus, Pertussis EPI Expanded programme on immunization FGD Focus group discussion HC Health Center HIV Human Immunodeficiency Virus HMIS Health management information system IMEESC Integrated management for emergency and essential surgical care IMCI Integrated management of childhood illness IPT Intermittent preventive treatment ITN Insecticide-treated bed nets IV Intravenous MDR-TB Multi-drug resistant tuberculosis MNCAH Maternal, neonatal, child, and adolescent health NCD Non-communicable disease ORS Oral rehydration solution PMTCT Prevention of mother-to-child transmission RDT Rapid diagnostic test SARA Service availability and readiness assessment STI Sexually transmitted infection TB Tuberculosis UDHS Uganda demographic and health survey UNICEF The United Nations Children's Fund UNFPA United Nations Population Fund USAID United States Agency for International Development VTS Voluntary Testing Services WHO World Health Organization 3 Contents Acknowledgements ....................................................................................................................................... 2 List of Acronyms ............................................................................................................................................ 3 Contents ........................................................................................................................................................ 4 Executive Summary ....................................................................................................................................... 6 1. Introduction and background ............................................................................................................... 9 1.1 Introduction .................................................................................................................................. 9 1.2 About the rapid assessment ....................................................................................................... 10 1.3 Rationale of the assessment ....................................................................................................... 10 2. Rapid assessment methods ................................................................................................................ 12 2.1 Framework for assessment ......................................................................................................... 12 2.2 Data collection methods ............................................................................................................. 12 2.3 Health facilities included in the assessment ............................................................................... 13 2.4 Assessment reach ....................................................................................................................... 15 3. Findings ............................................................................................................................................... 15 3.1 Malaria in the assessed facilities ................................................................................................. 15 3.2 Staffing levels .............................................................................................................................. 16 3.3 Training and capacity development ............................................................................................ 16 3.4 Availability of reference materials .............................................................................................. 17 3.5 Treatment of severe malaria ...................................................................................................... 18 3.6 Referral of cases of severe Malaria ............................................................................................. 20 4. Discussion ............................................................................................................................................ 23 4.1 Severe malaria case management policy issues ......................................................................... 23 4.2 Placement for injectable and rectal artesunate based on capacity ........................................... 24 4.3 Training and capacity development ............................................................................................ 25 4.4 Drugs and equipment ................................................................................................................. 25 4.5 Referral system ........................................................................................................................... 26 5. Conclusions and recommendations .................................................................................................... 27 5.1 Conclusions ................................................................................................................................. 27 5.2 Recommendations ...................................................................................................................... 27 References .................................................................................................................................................. 29 Annexes ....................................................................................................................................................... 30 4 Tables and figures referenced in the report ........................................................................................... 30 List of people at the national stakeholder meeting ................................................................................ 36 5 Executive Summary The National Malarial Control Programme (NMCP), Uganda commissioned this rapid assessment to gather evidence to help improve management of severe malaria, especially at the primary levels of the health delivery system. This follows the adoption of injectable artesunate (Inj AS) as a first-line treatment for management of severe malaria in both children and adults; and the further expansion of management of severe malaria in children to include the use of rectal artesunate (RAS) as a pre-referral intervention. The rapid assessment explored how Uganda can enhance case management of severe malaria at primary level health facilities (III & IV) which are closest to communities and should serve as the first point of contact for health services for many people. The objectives of the assessment were to explore the capacity of severe malaria service delivery at selected primary level health facilities, identify challenges and opportunities for improving service delivery and provide recommendations on how identified gaps can be addressed. The assessment was limited to 13 health facilities, including six level IV, six level III health centres and the Children’s Ward of Jinja Regional Referral Hospital (JRRH). Data used in the assessment was collected using multiple methods, including literature review, an audit of health facilities, and qualitative methods including health facility staff interviews, key informant interviews with village health teams, community level focus group discussions (FGDs), and consultation meetings with district and national stakeholders. Results Staff were performing the expected functions across all 13 health centres visited, including triaging patients, diagnosing and treating. Level III health facilities had shorter waiting times on average (between 5 and 30 minutes), while waiting times for some Level IV facilities were reportedly more than 2 hours. The quality of service provided by Level III facilities varied. With regards to severe malaria management, most facilities mentioned that they had staff who had been trained in malaria microscopy or the use of RDTs. Most staff mentioned having received some form of training on Inj AS, while staff from only four of the 13 facilities mentioned that some training had been received for using RAS. Many were not aware of any training on RAS, nor on its use as pre- referral intervention. It was difficult to establish if a structured continuing medical education (CME) programme existed for health facility personnel in the four districts that were visited. The first-line treatment for complicated malaria was mainly reported as Inj AS, however some health workers preferred to use quinine to artesunate. In many cases, stock outs were common; Inj AS was not available in three facilities and RAS
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