Through integrating services, increased advocacy, and messaging for both COVID-19 and malaria, Uganda has managed to avert the projected doubling of deaths due to malaria in 2020.
Malaria is a leading cause of death in Uganda. According to the World Health Organisation (WHO) World Malaria report, in 2019 Uganda accounted for three per cent of global malaria deaths. In April, the WHO projected in a modeling analysis double malaria deaths and a 22 per cent increase in infections across sub-Saharan Africa in 2020 due to severe disruptions to insecticide-treated net campaigns and lack of access to antimalarial medicines
In the same month when the rains began and after the Uganda ministry of Health confirmed 97 positive cases of COVID-19, a new nationwide campaign; "Why survive COVID-19 and die from malaria?" was adopted.
Dr Jimmy Opigo, the assistant commissioner for Health Services at the ministry of Health said the main advocacy message was that both diseases would be fought together. Infections surge during the rainy season and COVID-19 initially paralyzed the distribution system and created uncertainty as lockdowns limiting movement and fears of visiting health facilities became real.
President Yoweri Museveni made a directive for all market vendors to sleep where they work to avoid contact with their families to curb COVID-19 and in one of the efforts to integrate the two diseases, Museveni also directed the ministry of Health to distribute insecticide-treated nets to all vendors sleeping in city markets and fumigate surrounding areas.
According to the Roll Back Malaria (RBM) Partnership to End Malaria, countries' heroic efforts and strong leadership are helping prevent a projected doubling of malaria deaths in sub-Saharan Africa this year and are on track to achieve or maintain zero malaria cases and deaths.
"Malaria's impact in 2020 would have been much worse if not for the incredible efforts by countries and their partners, but the reality is that every malaria death today is avoidable. We must continue to tackle malaria and COVID together to save more lives and protect health systems," said Dr Abdourahmane Diallo, CEO of the RBM Partnership to End Malaria.
Medard Rukaari, the officer in charge of universal bed net distribution at the Uganda National Malaria Control Programme (NMCP) says they integrated services for COVID-19 and malaria which is cost-effective as they use the human resource targeting the same communities.
The outcome was a COVID-19/malaria campaign with co-messaging linking the two diseases.
"All the malaria campaign messages for insecticide-treated bed net distribution have a COVID-19 message," says Rukaari. "It is a smart campaign, extremely effective with comprehensive messaging."
According to the RBM Partnership, despite the COVID-19 pandemic, over 90 per cent of life-saving campaigns went on in 28 countries: 200 million mosquito nets are on track to be delivered by the end of the year and over 20 million children have been reached with seasonal malaria chemoprevention.
"We cannot let the COVID-19 pandemic distract us from redoubling our efforts to protect hard-fought gains against malaria and accelerating efforts to end this disease within a generation," said Professor Maha Taysir Barakat, RBM Partnership Board Chair.
"Ending malaria will also enable countries to manage other diseases, as well as current and emerging health threats. With ongoing commitment, optimized use of current resources, and new investments, we can deliver on the promise of a malaria-free world."
In Uganda, the integration of services for malaria and COVID focussed on using the insecticide-treated bed net as a launch product as the government worked with partners like WHO, Malaria Consortium, UNICEF, and others to issue guidance and train health workers at the national and district levels on how to ensure key medical services were provided safely.
Dr Bayo Fatunmbi, who heads the disease prevention and control team at the WHO office in Uganda said the supply of critical material for malaria suffered disruptions as production lines of many biomedical firms shifted towards COVID-19 supplies, slowing down the manufacture and distribution of materials such as rapid test kits for malaria.
Dr Anthony Nuwa, the senior country technical coordinator, Malaria Consortium Uganda says with support from MasterCard Foundation they supplied personal protective equipment (PPEs), such as gloves, face masks, hand sanitizer, and goggles to all community agents, as well as delivered hand washing equipment to health facilities to continue and observe the standard operating procedures (SOPs) during the malaria campaign.
Teams conducting household registration and distribution of insecticide-treated nets were also provided with PPEs.
"Considering the global shortage of PPEs, cloth masks, gloves, sanitizers, re-usable aprons, and gumboots for use due to heavy rains during this campaign were sourced from local manufacturers," says Rukaari.
For instance, a total of 500,000 masks were manufactured locally per day with a final total of 34 million supplied for the campaign activities.
The campaign became digital:
The government ensured that all efforts to control the spread of COVID-19 including social distancing were maintained during the malaria campaign and net distribution. This too required that the exercise becomes digital. Dr Nuwa who also heads the malaria-COVID task force says all their meetings turned virtual and they created a malaria/COVID platform to continue to support the continuity of services in malaria prevention.
Ordinarily, the nets are distributed in public gatherings – an impossible option given the pandemic. Data was captured electronically through the Electronic Data Management System (EDMIS) and also through the Collaborative Communication Management Information System (CCMIS) which captures all other data including supervision.
As such recipients were registered through a mobile phone-based App and nets were delivered door-to-door by small teams concurrently. Tracking the distribution of the nets was done digitally.
"We run a paperless and cashless campaign and changed the delivery mechanism which has meant the number of days we used to spend have increased," says Rukaari.
Furthermore, the change to mobile money was implemented as cash could be a source of COVID-19 transmission. Equally, no signatures for payment were mandated due to concerns that paper could be a source of COVID-19 transmission.
For the household registration and ITN distribution, data entry clerks were part of every team. Due to COVID-19, the data entry clerks used their own smartphones rather than having the NMCD procure them separately. Used for the first time the digital system created its challenges - people wanted to register everyone inflating the numbers per household and validation was difficult.
"We cannot say we have distributed more bed nets than would be and the budget has not really increased," said Rukaari.
Out of 29 million bed nets meant to be distributed as of early 2020, more than 19 million have so far been given to households. Another 10 million will be distributed by February 2021 in Kampala, Wakiso, and surrounding districts.
An additional 1.4 million bed nets by Against Malaria Foundation (AMF) to respond to anticipated gaps freed up part of the Global Fund financial resources used in the procurement of PPEs. AMF in January signed an agreement with the Uganda Ministry of Health to fund 50 per cent of Uganda's insecticide treated net need of 27.5 million for the 2020 universal coverage campaign.
Distribution of insecticide-treated nets was done in a waved approach and a total 39 districts were covered in the third wave.
The first wave mostly covering the eastern region with 25 districts and the second wave covering the western region with 28 districts is already covered, according to NMCP and total distribution since the exercise began stands at 90 per cent. The last or fifth wave targeting Kampala and Wakiso districts will be done in February 2021.
"Given the current election time politicians have supported the campaign and worked with the Uganda National Malaria Control Programme to deliver the bed nets and get to the last mile," said Rukaari.
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