An assessment of malaria prevention, diagnosis and treatment services in Uganda

Kimbugwe, Hassan (2022-04)

Thesis (PhD)--Stellenbosch University, 2022.

Thesis

ENGLISH SUMMARY: Government, donor partners, and the private sector invest large amounts of financial resources annually in malaria prevention and care. Despite substantial spending on malaria prevention programmes by 2019/2020, the disease still accounted for 13.3% Uganda's mortality, as well as 29.8% of outpatient visits and 34.9% of inpatient admissions. To combat malaria more effectively, it is critical to understand whether these substantial investments in malaria prevention and care reach those who are most vulnerable to malaria, and whether approved malaria diagnosis and treatment protocols are followed diligently. This PhD was thus structured to consider three distinct but related issues: (i) the equity of bed net use and ownership in 2009 and 2014, (ii) the uptake of malaria prophylaxis amongst pregnant women, and (iii) the relationship between financial incentives and appropriate malaria diagnosis and case management. The first essay examines the equity in access to and utilisation of bed nets in 2009 and 2014. It was found that the availability of bed nets increased over time. Access to and use of bed nets became more equitable, with higher levels of access and use amongst poorer households. Households with access to at least one bed net rose from 59.2% to 94.1%. The percentage of households who slept under bed nets increased from 51.8% to 72.6%. The percentage of children under five years who slept under bed nets increased from 45.8% to 81.5%. The percentage of pregnant women who slept under bed nets increased from 78.6% to 83.8%. Through recentered influence functions (RIF) decomposition method, the study examined whether the demographic factors were associated with the relationship between the wealth index and bed net utilisation in 2009 and 2014. Results suggest that in 2009, place of residence, number of nets in a household, mother’s education level, region and household size were associated with the relationship between wealth index and bed net utilisation. In 2014, age of household members, and mother’s education level were associated with the relationship between the wealth index and bed net utilisation. In both years having a mother with at least primary level of education was vital in promoting bed net utilisation. The results further indicate that younger household members, women, household members from the northern region, household members from the poorest wealth quintile, mothers with a post-secondary education, and households with more bed nets and few members were more likely to sleep under bed nets in 2014. The second essay reviews factors associated with uptake of intermittent preventive treatment (IPT) of three doses of Sulfadoxine-pyrimethamine (SP) (IPT-SP3) during pregnancy. The analysis indicated a double and notable improvement in uptake over time, from 9.91% in 2011 to 17.89% in 2016. However, the uptake was still far below the 79% target of Uganda’s Health Sector Strategic Plan (Uganda Ministry of Health (MoH) 2014). Results showed that uptake was higher amongst younger women (under the age of 25 years) than older women (above the age of 34 years), higher amongst women who attended their first antenatal care (ANC) visit early (during the first trimester) than those who attended later (during the third trimester), higher amongst women from the upper wealth quintile than women from the poorest quintile, and higher amongst women from the northern region of Uganda than among women from the central region. Results also indicated that uptake of IPT-SP3 was lower amongst women from the western region than women from the central region. Findings from the pooled model (unrestricted) indicate that the relationship between IPT-SP3 and the covariates in the two different time period (2011 and 2016) have not changed. The third and final essay focuses on the relationship between financial incentives and the likelihood of private providers adhering to national guidelines on malaria diagnosis and dispensing practices. The specific concern is that volume or revenue-based staff remuneration may provide a strong incentive for provision of malaria drugs to patients who have not yet tested for malaria. This tension is observed in a subsample where facilities do not have malaria testing capabilities and only sell malaria treatment and staff are paid based on the volume of drugs sold or the revenue. The results suggest that the private healthcare providers who receive salaries are more likely to adhere to malaria treatment protocols. Descriptive findings indicate significant variations between drug-shop attendants and other private healthcare providers with regard to malaria diagnosis, antimalarial dispensing practices, and adhering to malaria treatment procedure.

AFRIKAANSE OPSOMMING: Die regering, donateursvennote, en die private sektor belê jaarliks groot hoeveelhede finansiële hulpbronne in die voorkoming en behandeling van malaria. Ondanks aansienlike besteding aan malariavoorkomingsprogramme teen 2019/2020 was die siekte steeds verantwoordelik vir 13.3% van Uganda se sterftesyfer, sowel as 29.8% van buitepasiëntbesoeke en 34.9% van opnames van binnepasiënte. Om malaria doeltreffender te bestry, is dit van kritieke belang om te verstaan of hierdie aansienlike beleggings in die voorkoming en behandeling van malaria diegene bereik wat die kwesbaarste vir malaria is, en of goedgekeurde diagnostiese en behandelingsprotokolle vir malaria nougeset gevolg word. Hierdie PhD was dus gestruktureer om drie verskillende maar verwante kwessies te oorweeg: (i) die ekwiteit van die gebruik en besit van bednette in 2009 en 2014, (ii) die opname van malaria-profilakse onder swanger vroue, en (iii) die verband tussen finansiële aansporings en die toepaslike malariadiagnose en gevallebestuur. Die eerste opstel ondersoek die ekwiteit van toegang tot bednette en die gebruik daarvan in 2009 en 2014. Daar is bevind dat die beskikbaarheid van bednette oor tyd toegeneem het. Toegang tot en gebruik van bednette het billiker geword, met hoër vlakke van toegang en gebruik onder armer huishoudings. Huishoudings met toegang tot minstens een bednet het van 59.2% tot 94.1% gestyg. Die persentasie huishoudings wat onder bednette geslaap het, het van 51.8% tot 72.6% gestyg. Die persentasie kinders onder die ouderdom van vyf jaar wat onder bednette slaap het van 45.8% tot 81.5% gestyg. Die persentasie swanger vroue wat onder bednette slaap het van 78.6% tot 83.8% toegeneem. Die bevindings dui daarop dat jonger huishoudings, vroue, huishoudelike lede in die noordelike streek, huishoudings in die armste rykdomskwintiel, moeders met naskoolse opleiding, en huishoudings met meer bednette en min lede in 2014 meer geneig was om onder bednette te slaap. Die tweede opstel ondersoek wat verband hou met die opname van intermitterende voorkomende behandeling tydens swangerskap van drie dosisse sulfadoxine-pyrimethamine. Die ontleding dui op 'n klein maar beduidende verbetering oor tyd, van 9.91% in 2011 tot 17.89% in 2016, in die persentasie vroue wat drie dosisse ontvang het. Die verbetering was egter nog ver onder die teiken van 79% wat deur Uganda se Strategiese Plan vir die Gesondheidsektor gestel is. Bevindinge toon dat die opname hoër was onder jonger vroue (onder die ouderdom van 25 jaar) as onder ouer vroue (bo die ouderdom van 34 jaar), en hoër onder vroue wat hul eerste voorgeboortesorgbesoek vroeg bygewoon het (binne die eerste trimester) teenoor diegene wat dit later bygewoon het (in die derde trimester), hoër onder vroue uit die boonste rykdomskwintiel as onder vroue uit die armste kwintiel, hoër onder opgeleide vroue teenoor dié met geen opleiding, en hoër onder vroue uit die noordelike as die sentrale streek van Uganda. Resultate dui ook aan dat die opname van drie dosisse laer was onder vroue uit die westelike streek, vergeleke met die sentrale streek. Die derde en laaste opstel fokus op die verband tussen finansiële aansporings en die waarskynlikheid dat private verskaffers die nasionale riglyne ten opsigte van diagnose en reseptering van malaria volg. Beskrywende bevindings dui op beduidende variasies tussen medisynewinkels se assistente en ander private verskaffers van gesondheidsorg rakende malariadiagnose, behandeling, en die nakoming van die prosedure vir die behandeling van malaria. Die resultate van die studie dui daarop dat die finansiële aansporings wat aan private verskaffers van gesondheidsorg gegee word positief verband hou met die nakoming van behandelingsprotokolle vir malaria. Bevindinge toon dat pasiënte met negatiewe resultate van malaria waarskynlik antibiotika ontvang sonder dat volle bloedtellings, soos aanbeveel deur die kliniese riglyne, gedoen word.

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