Uganda introduces kits to cut malaria treatment costs

By Esther Nakkazi

Uganda will reintroduce malaria test kits in health facilities nationwide to facilitate malaria diagnosis that could improve the management of the disease.

From next month, National Medical Stores (NMS), the Uganda government’s supplier of pharmaceuticals products, will distribute Rapid Diagnostic Tests (RDTs) that could save thousands of doses of anti-malarials.

The RDTs will enable health workers to detect the presence of malaria within a few seconds cutting down on over diagnosis, time and over prescription of malaria, health experts say.

Research has established that for every 20,000 doses supplied per month to a district, up to 16,000 doses of anti-malarials are saved when health workers use RDTs.

Some of the $90 million from the Global Fund and government resources will be used to buy RDTs that will not only stop presumptive diagnosis, a common practice among most health workers but also avert a tendency of stocking medicines in houses that has cropped up.

Presumptive treatment identifies the likely condition a patient has; it is widely practiced where microscopy or RDTS are not readily available.

Most health workers use presumptive diagnosis, giving all patients anti-malarials after they present with headaches, fever and loss of appetite. In most cases the health workers are ‘playing safe’ especially with children who progress rapidly to severe malaria and death.

But also recently after the switch from the user driven for drug selection and quantification-pull system to the ‘modified’ push system where government estimates pharmaceutical supplies required, the public has adopted a tendency to pick drugs even when they are not sick.

“People line up pretending to have all sorts of illnesses especially malaria and keep the medicines for a rainy day while others sell them off,” said Moses Kamabare the General Manager, National Medical Stores.

Typically when NMS delivers medicines to health facilities, which is once every two months, in just about 2 weeks the Coartem would be finished. “RDTs would ensure that they pick medicines especially Coartem, which is very expensive only when required.”

There is no doubt that using RDTs is a cost effective venture in the treatment of malaria as has been tested in Zanzibar and Ghana. In Uganda, Government supplies free ACTs to all government health facilities but on the open market a dose costs Ushs 15,000 ($7).

Indeed, when an RDT test is administered that turns out negative, Ushs 10,000 ($4) would be saved for every patient. This would save lots of money as few people who claim to have malaria actually have it, but would also ensure reduction of over exposure of the population to drug toxicity.

A study by Malaria Consortium Uganda, found that use of RDTs resulted in a 2-fold reduction in anti-malarial drug prescription at Low Level Health Care Facilities (LLHCFs). The study entitled the ‘Use of RDTs to improve malaria diagnosis and fever case management at primary health care facilities in Uganda’ was published in July 2010. 

Dr. Daniel Kyabayinze the principal investigator of the study said they found that when RDTs are administered only 20-40 percent of patients who claim to have malaria would have it, so it is very cost effective.

The study says that nationwide deployment of RDTs in a systematic manner should be prioritized to improve fever case management but cautions that there is need to further educate health workers about use of RDTs in order to maximize acceptance.

“The study found that 1/3 times a person will have a negative test but the health worker will give them anti-malarials anyway,” says Dr. Kyabayinze from Malaria Consortium Uganda.

In the study, health workers said they treat RDT-negative patients because they are afraid of challenges of severe malaria given the long distances to the referral hospitals in case need arises.

Also, among negative patients with RDT results, children under five years were nearly 3 times with more likely to receive anti-malarials relative to older patients, a practice that is in line with the national malaria treatment policy.

The policy encourages presumptive treatment of malaria to reduce malaria-associated morbidity among the under-five age group who contribute a third of the anti-malarial prescriptions for RDT negative results.

“It is likely that health workers found it socially acceptable to offer anti-malarials to RDT negative patients but also that they appreciate the medical care provided,” says the study. But there are also questions of the accuracy of RDTs in diagnosis. 

 
Research shows that 90 percent of the times when the RDT test is positive, the patients have malaria, but the test also picks past infection in the last 2 weeks.

“It is important that those who come in and the test is negative are not given anti-malarials because the test would be 98 percent negative,” said Dr. Kyabayinze.

With the study results government is working on a policy that will ensure that all people who are treated with anti-malarials first get a malaria test.

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