An epidemiological profile of malaria and its control in Uganda Report prepared by National Malaria Control Programme, Kampala, Uganda & The INFORM Project Department of Public Health Research Kenya Medical Research Institute - Wellcome Trust Progamme Nairobi, Kenya October 2013 Acknowledgments The authors are indebted to the following individuals from the INFORM Project, KEMRI- Wellcome Trust programme: Emelda Okiro, Ngiang-Bakwin Kandala, Caroline Kabaria, Damaris Kinyoki, Stella Kasura and Jonesmus Mutua; We are also grateful to the help provided by Andrew Balyeku in geo-coding health facilities in July 2013, Didas Namanya of the ministry of health, planning department for help with administrative unit information, the WHO country office –mTRAC project for parts of the health facility inventory, and Catherine Linard for assistance on modelling human population settlement. We are grateful to the technical leadership of the Uganda Ministry of Health for agreeing to sign the MoU that facilitated this collaborative work. We acknowledge in particular all those who have generously provided unpublished data, helped locate information or the geo-coordinates of data necessary to complete the analysis of malaria risk across Uganda: Jane Achan, Seraphine Adibaku, Miriam Akello, Paul Ametepi, Martha Betson, Teun Bousema, Simon Brooker, Clare Chandler, Jon Cox, Deborah DiLiberto, Grant Dorsey, Thomas Egwang, Allison Elliot, Francesco Grandesso, Jean-Paul Guthmann, Stephen Hillier, Narcis Kabatereine, Rita Kabuleta-Luswata, Mark Kaddumuka, Ruth Kigozi, Simon Kigozi, Macklyn Kihembo, , Catherine Maiteki-Sebuguzi, Fred Kironde, Steve Kiwuwa, Moses Kizza, Jan Kolaczinski, Steve Lindsay, Caroline Lynch, Godfrey Magumba, Edith Mbabazi, Catherine Maiteki, Dida Manya, Patrick Monami, Levi Mugenyi, Lawrence Muhangi, Charlotte Muheki, Halima Naiwumbwe, Zaria Nalumansi, Ruth Nanyonga, Florence Nankya, Sussann Nasr, Juliet Ndibazza, Gloria Oduru, Ambrose Onapa, Niels Ornbjerg, Erling Pedersen, Carla Proietti, Rachel Pullen, Denis Rubahika, John Rwakimari, Paul Simonsen, James Ssekitoleeko, Sarah Staedke, Claire Standley, Laura Steinhardt, Anna- Sofie Stensgaard, Rus Stothard, James Tibenderana, Henry Wannume, Emily Webb and Adoke Yeka. The authors also acknowledge the support and encouragement provided by the Ugandan RBM partnership, Dr Alistair Robb, the UK government's Department for International Development (DFID) regional malaria advisor and Dr Thomas Teuscher of RBM. This work was supported by grants from The Wellcome Trust, UK to Professor Bob Snow (# 079080) and Dr Abdisalan Mohamed Noor (# 095127) and a contract between the University of Oxford and RBM with funds provided by DFID-UK. Suggested citation National Malaria Control Programme, Abt Associates and the INFORM Project (2013). An epidemiological profile of malaria and its control in Uganda. A report prepared for the Ministry of Health, the Roll Back Malaria Partnership and the Department for International Development, UK. October, 2013 2 Author details Ambrose Talisuna, Abdisalan M Noor, Clara W Mundia, Viola Otieno, Bernard Mitto, Punam Amratia & Robert W Snow The INFORM Project Department of Public Health Research KEMRI-Wellcome Trust Collaborative Programme P.O.Box 43640 00100 Nairobi, Kenya emails: [email protected]; [email protected]; [email protected] John B Rwakimari & Michael Okia Abt Associates Plot 3 Solent Avenue Mbuya, P.O.Box 37443 Kampala, Uganda emails: [email protected]; ; [email protected] Peter Albert Okui National Malaria Control Programme, Ministry of Health Plot 6 Lourdel Road, P. O. Box 7272 Kampala, Uganda email: [email protected] 3 Table of Contents Executive Summary .............................................................................................................................. 13 Chapter 1: Introduction ........................................................................................................................ 15 Chapter 2: Country context, administration, population distribution and health service provision ... 19 2.1 Location ....................................................................................................................................... 20 2.2 Political and social evolution ....................................................................................................... 20 2.3 Economy ...................................................................................................................................... 22 2.4 Poverty ........................................................................................................................................ 23 2.5 Child Survival ............................................................................................................................... 24 2.6 Administrative boundaries .......................................................................................................... 26 2.7 Population growth and distribution ............................................................................................ 27 2.8 Urbanization ................................................................................................................................ 29 2.9 Evolution of current health system ............................................................................................ 31 2.10 Health facility mapping ............................................................................................................. 33 2.11 References................................................................................................................................. 37 Chapter 3: 100 years of malaria control in Uganda .............................................................................. 40 3.1 Background ................................................................................................................................. 41 3.2 Malaria control 1900 to 1950 – the early years ......................................................................... 41 3.3 Malaria control 1950-1969: Pre-eradication planning ................................................................ 44 3.3.1 Malaria eradication experimental pilot projects ............................................................ 45 3.3.1.1 Northern Kigezi, Western Uganda, 1959-64 ................................................... 45 3.3.1.2 Kigezi highlands 1960-1964 ............................................................................ 46 3.3.1.3 Field trials of Malathion in Masaka, southern Uganda 1963-1964 ................ 46 3.3.1.4 Chloroquine medicated salt malaria suppression Lugazi & Kakira 1964-1965 .................................................................................................................................... 47 3.3.2 Other pre-eradication activities in Uganda 1950s-1960s ............................................... 48 3.4 Malaria control 1970-1995: apathy to renewed interest ........................................................... 48 3.5 Malaria control 1995-2001: defining the challenge .................................................................... 49 3.5.1 Restructuring of the malaria control unit and district management ............................. 51 3.5.2 Assembling morbidity and mortality data and defining the epidemics .......................... 52 3.5.3 Grappling with antimalarial drug resistance & the first drug policy change .................. 53 3.5.4 Malaria prevention strategies and coverage 1996-2001 vs available funds .................. 55 3.6 Malaria control 2001-2005: The early days of Roll Back Malaria (RBM) .................................... 58 3.6.1 National strategy 2001-2005 .......................................................................................... 58 3.6.2 Changing funding landscape for malaria prevention and control ................................. 58 3.6.3 Changing staff and structure of MCU ............................................................................ 58 3.6.4 Vector control ................................................................................................................. 59 3.6.4.1 Urban malaria control ..................................................................................... 59 3.6.4.2 Insecticide treated nets .................................................................................. 59 3.6.4.3 IRS ................................................................................................................... 61 3.6.5 IPTp ................................................................................................................................. 61 3.6.6 Increasing access to malaria treatment in the home ..................................................... 61 3.6.7 The second antimalarial treatment policy change and implementation 2004-2007 ..... 62 3.7 Malaria Control 2005-2010: RBM going to scale ........................................................................ 63 3.7.1 National Malaria Strategy 2005-2010 ............................................................................. 63 3.7.2 Funding and staff changes 2005-2010 ............................................................................ 63 4 3.7.3 Vector control from 2007 ............................................................................................... 64 3.7.3.1 ITN ..................................................................................................................