Improving Malaria Case Management in One Ugandan Hospital

Malaria is the leading cause of outpatient visits in Uganda (Ministry of Health, Annual Health Sector Performance Report, 2015/2016), and prevention, diagnosis, and treatment are crucial for reducing preventable deaths, lowering the risk of resistance to antimalarial medicines, and decreasing medicine wastage and misuse. 

To tackle inappropriate practices in malaria testing and treatment, the USAID-funded Uganda Health Supply Chain (UHSC) program helped the Moroto regional referral hospital in northeastern Uganda revitalize its Medicine and Therapeutics Committee (MTC), which works to strengthen health systems and reduce practices that lead to morbidity by improving medicine use and quality of care in health facilities.

Working with the Ministry of Health’s Pharmacy Department, the UHSC program trained Moroto’s MTC members on improving appropriate medicine use, generating and using data to investigate problems, and designing interventions to address them. Through its new practices, the MTC determined that the most critical medicine use problems were poor adherence to the national malaria test-and-treat policy; excessive use of injectable medicines, especially antibiotics, in the outpatient department; and poor tracking of the medicines flow from store to patient.

The MTC determined that correcting inappropriate practices in malaria testing and treatment was its highest priority. Members saw that too many patients were diagnosed with malaria and prescribed artemisinin-based combination therapy (ACT) even though they had not been tested or tested negative. A few cases had even received ACT without a malaria diagnosis.

The MTC embarked on a phased approach to improve adherence to the test-and-treat policy. The first step was to introduce rapid diagnostic tests (simple tests that do not require specialized equipment or personnel) in outpatient clinics and wards so that nurses could quickly test patients. Informational sessions were held with prescribers on the importance of the test-and-treat policy. Pharmacy staff were instructed to dispense antimalarial medicines only to patients with positive test results and a prescription from an authorized prescriber. Because patient requests for specific medicines could influence clinicians’ prescribing decisions, regular patient education sessions were also held in the outpatient department.

The MTC’s second step was to collect monthly data on a sample of 100 outpatients being treated with ACT to verify adherence to the test-and-treat policy. The monthly survey proved the intervention’s success. Since the survey was implemented in May 2017, the testing rate among patients receiving ACT increased from 45% to 86% in March 2018, and the percentage of patients receiving treatment with a negative test result decreased from 31% to 9% in the same time period. In addition, the percentage of patients treated who had tested positive increased from 14% to 77%.

Dr. Francis Alfred Ogwang, Moroto’s MTC chair, said, “The MTC has given us a good basis for decision-making. We can now track medicine use and minimize the unnecessary waste of our antimalarial medicines.” Following the initial success of Moroto’s MTC, directors of several other regional referral hospitals; managers from Uganda’s Catholic and Protestant medicine bureaus; and two private, for-profit hospitals have expressed interest in establishing or revitalizing MTCs in their facilities.

Moving forward, the Moroto MTC will work to reduce the excessive use of injectable medicines and antibiotics in the outpatient department. Dr. Ogwang is confident of the Moroto MTC’s sustainability because of “reliable and skilled personnel, management commitment, resources, and engagement platforms with staff and patients through continuous medicines education and patient education sessions.” He stressed the importance of the hospital leadership’s commitment as critical to ensuring that the MTC has a sufficient budget and resources to succeed.