In 2010, the World Health Organization recommended that every suspected malaria case be confirmed by an approved parasitological test prior to treatment. Subsequently, the Uganda Ministry of Health (MoH) adopted these guidelines and switched policy from presumptive treatment of malaria to targeted treatment, hence the test, treat, and track policy.

This policy not only strengthens surveillance of confirmed malaria cases, but also affords the country much benefit including minimized wastage of drugs, avoiding selection of drug resistance, and reducing exposure of patients to adverse events associated with unnecessary anti-malarial drug treatments. Despite all the efforts taken to operationalize the policy, reports indicated that antimalarial therapy continues to be prescribed even following a negative malaria test result or even without conducting a test.

However, there was a dearth of information on the extent and specific reasons for non-adherence to the malaria test, treat, and track policy. With funding from the Global Fund through the National Malaria Control Division of the MoH, the Public Health Fellowship Program conducted a study to describe and document malaria testing practices in healthcare facilities, assess the levels of non-adherence to the policy by clinicians, determine factors associated with non-adherence to malaria test results, and assess capacity for malaria surveillance in Uganda.

This was a cross-sectional survey of healthcare facilities conducted in 29 randomly selected districts from all the 15 regions in Uganda. From each district, facilities were randomly selected across the levels of healthcare and ownership.

Data collection employed a mix of qualitative and quantitative methods including document review of malaria data from the Health Management Information System, review of healthcare facility data; and primary data collection through a health facility-based survey and key informant interviews (KII).

We reviewed the outpatient department (OPD) register, and laboratory register. KIIs were conducted across all levels, including national, regional, and district levels.

We interviewed 360 healthcare workers, 1,506 patients, and 140 health facilities. Majority of the health workers interviewed were Clinical Officers, 35% (127/360), followed by enrolled nurses, 21% (76/360). The mean duration in service was 108.7 months and at the OPD was 56.2 months.

We found that the mean testing rate in the selected facilities was 60.7%, while the mean proportion of patients with positive tests that were treated with ACT was 96.3%, higher than the national target at 95%. The mean proportion of negatives that were treated with ACT was higher than the 5% national target at 9.9%. Up to 92.5% (333/360) of health workers reported that malaria test, treat, and track guidelines were accessible at their facilities.

The most commonly used symptoms used by health workers to suspect malaria were fever (99%), vomiting (76%), and headache (76%). We found that 41% of health workers had received training on the policy. Only 6.6% (24/360) of the health workers had ever treated a patient for malaria without testing and up to 22.6% (81/360) of the health workers had ever treated a malaria negative case with an anti-malarial.

The most reported reasons for treating malaria negative cases with an anti-malarial were workload and lack of trust in laboratory personnel. Lack of testing facilities was mentioned among 76% of respondents as the reason for low testing rates as well as rejection of malaria test by patients at 20.3%. Microscopy at 75.8% (273/360) was the most conducted test to diagnose malaria. Only 38.4% (138/360) of the health workers reported to have antimalarial drugs whenever they wanted to use them.

Outbreaks (49%) and undersupply (46%) were the most reported reasons for antimalarial stockouts. During the study period, only 12% of health facilities had stockouts of antimalarial drugs and mRDTs. Up to 38.7% (139/360) of health workers reported that a patient had ever rejected their malaria result; and 37.2% (134/360) of health workers reported that a patient has ever rejected the malaria treatment recommended, 67% of patients preferring another drug. Only 4.7% (71/1,506) of patients interviewed reported having ever opted not to be tested for malaria, implying majority of patients, 95.3% (1435/1,506) opted for a malaria test before treatment.

Self-diagnosis (27.5%), fear of pain due to pricks (20.3%), long waiting time (18.8%) and expensive test (15.9%) were the most commonly reported reasons why patients opted not to be tested for malaria. Most 67.1% (1010/1,506) of the patients reported that they had never treated themselves with antimalarial drugs without testing. Majority 82.3% (1,237/1,506) of the patients reported that they had never taken antimalarials after a negative malaria test.

The study revealed that even though less than half of healthcare workers had been trained on the policy, majority of them were aware of the malaria test, treat, and track policy. Adherence to the malaria test, treat, and track policy among health workers and patients were good.

However, a high number of patients who either tested negative or are not tested are still being prescribed antimalarial drugs. Majority of patients who tested positive for malaria were treated with ACTs. Stockout of antimalarial drugs and rapid test kits was low.

We recommended that MoH ensures constant supply of testing reagents, kits, and anti-malarial medicines in all healthcare facilities; facilities should ensure there are frequent continuous medical education sessions, including malaria test, treat and track; and intense surveillance for early identification and response to malaria outbreaks.