Case management of severe malaria - a forgotten practice: experiences from health facilities in Uganda

This journal article describes a study which highlights the serious challenges faced in the management of severe malaria in a resource limited setting like Uganda. The study was conducted to evaluate the management practices for severe malaria in Ugandan health facilities, using instruments adapted from the WHO hospital care assessment tools.

The study was based on a cross sectional survey, using multi-stage sampling methods, of health facilities in 11 districts in the eastern and mid-western parts of Uganda. Between June and August 2009, 105 health facilities were surveyed and 181 health workers and 868 patients/caretakers interviewed. None of the inpatient facilities had all seven components of a basic care package for the management of severe malaria consistently available during the 3 months prior to the survey.

The study found that:

• referral practices were appropriate for 10 per cent of the patients
  
• prompt care at any health facility was reported by 29 per cent of patients
  
• severe malaria was correctly diagnosed in 27 per cent of patients
• though the quinine dose and regimen was correct in the majority of patients, it was administered in the correct volumes of 5 per cent dextrose in only 18 per cent 
  
• most patients had several doses of quinine administered in one single 500 ml bottle of 5 per cent dextrose
  
• medications were purchased by 44 per cent patients and medical supplies by 70.6 per cent of patients.
  

The article describes significant problems with case management at both the health system/health centre and provider levels. It concludes that management of severe malaria in Ugandan health facilities was sub-optimal with most facilities not fully complying with the national and international treatment guidelines.

The findings highlight the challenges of correctly managing severe malaria in resource limited settings. Considering the problems identified, several priority areas at different points of care needing improvement would include:

• triage and emergency care
  
• referral practises
  
• quality of diagnosis and treatment
  
• availability of medicines and supplies
  
• training and support supervision.