Lots of data and 'a strong backbone': How Uganda is making progress against malaria

Just over a decade ago, Time magazine dubbed Apac, Uganda, “the most malarial town on earth.” But, at that point, the same could have been said of many Ugandan villages. A national survey found that 55 percent of children under the age of five had malaria – one of the highest rates in the world.

Today, it's estimated that less than 17 percent of Uganda’s children have malaria. Across the board, Uganda’s malaria and malaria mortality rates have plummeted, with the incidence of malaria in Uganda falling by 46 percent and malaria mortality dropping 83 percent from 2000 to 2019.

To achieve this, the country has leveraged the full range of the most powerful anti-malaria tools. The most recent data from Uganda’s ministry of health shows that 83 percent of Ugandan households use insecticide-treated bed nets; 10 percent of households had indoor residual spraying in the past year; 89 percent of eligible women received at least one dose of preventative malarial treatment during pregnancy; the country distributes nearly 37 million rapid diagnostic tests annually; and more than 30 million courses of malaria treatment are administered annually.

When the country’s progress against malaria began to plateau four years ago, Ugandan officials reassessed their efforts and developed a more targeted, data-driven strategy that has helped them continue progress against the disease.

This strategy has five key parts.

First, health leaders recognized that the fight against malaria could not be won solely on the national level. They needed to invest in capacity building at the subnational level so that leaders at that level were empowered to adapt and target interventions to address local needs and challenges. “The fact is, any malaria strategy is only as good as your implementation,” said Jimmy Opigo, malaria program manager at Uganda’s ministry of health.

Uganda’s support for a decentralized approach allows for more flexible subnational planning and leadership. This is in line with research demonstrating that decentralized programs enhance "engagement in malaria elimination by subnational units and communities" and that "in most cases decentralization increased local level capacity of the malaria program as well as community access to health services.”

Second, Uganda invested in collecting more data of all types. For example, health officials launched a partnership to examine weather data and identified eight districts with a climate very much like the one in the Sahel, the semi-arid area just south of the Sahara. Unlike the rest of Uganda, which is typically humid all year round, these districts experienced rain only five months of the year. Officials then worked with global health experts to test whether the same seasonal malaria chemoprevention that has helped save lives in the Sahel could be used to protect children in those eight districts. The results have been game changing. Children in these districts are now 92 percent less likely to develop clinical malaria during the peak transmission season than those in other districts.

Uganda’s emphasis on data isn’t just about collecting any and all data. It is about collecting strategic data to make it actionable. For example, the government worked with researchers around the country who study mosquitos to standardize their collection tools and protocols, and also coordinate the locations of their research, to help make the data more complete and useful.

“You need a lot of data to decide what is the right tool in the right place at the right time,” said Opigo. “And you need to have a strong backbone to act on that data and say, ‘This area does not need this intervention at this time.”

The third key element, Opigo said, was effectively using this data. The government began to use computer modeling to determine the most strategic investments in 2018 and 2019 when funding for malaria was flatlining and the country was seeing diminishing returns for the precious dollars it was investing. The modeling has transformed Uganda’s strategy. Instead of chasing the goal of reaching everyone across the country with the same interventions, health leaders are taking a more targeted approach, to maximize the impact of limited funding.

The government, Opigo said, has worked with the Bill & Melinda Gates Foundation and the Global Fund to use computer modeling to determine optimal intervention packages and targeting. “Everyone wants to be evidence driven and everyone thinks they are evidence driven. But in reality, our personal opinions and biases cloud our judgement,” he said. “We have limited funds. We don’t need bed nets everywhere. Instead, we need to invest more intelligently. We can do that by using computer intelligence tools to guide our programming and optimize our impact.”

Fourth, based upon this data and modeling, the government created a national plan and is implementing it with the help of partners including, the Global Fund, the President’s Malaria Initiative, the Bill & Melinda Gates Foundation, and Rotary International clubs across the United States.

Fifth, the government encouraged the private sector to get into the malaria business – literally. It encouraged local businesses to sell mosquito aerosols, coils, and bed nets, among other things. This has allowed consumers to easily buy these products in the supermarket. Likewise, the government has been working with architects to design more mosquito-safe housing and encouraged a paint company to distribute its mosquito-repelling housepaint.

This month, the government also approved the launch of a private company that will use profits from indoor residual spraying services for middle class and wealthy Ugandans to help subsidize spraying services and government programs targeting low-income, high-risk communities.

“In the same way that people will buy a condom or a vitamin in a chemist shop, we want them to consider buying products to stop malaria,” said Opigo. “This requires a change in thinking among consumers. For too long, our focus was on early detection and early treatment of malaria. We are working on shifting people’s thinking to prevention and ensuring that they recognize that they must take responsibility for preventing mosquito bites by sleeping under a net, by covering themselves, by clearing standing water, and by using these products that are increasingly available.”

Despite Uganda’s progress, much work remains. In the country, malaria still accounts for almost 40 percent of visits to health care centers, about 20 percent of hospital admissions, and nearly 10 percent of deaths. In 2020, the country of 46 million reported more than 10 million malaria cases in 2020 alone (roughly five percent of global cases).