This essay is “determinants of health “in Uganda. The word account 2500-2700. It is paper review in
Vancouver style. I need improvement and editing for a re-sit examination. I will send you the essay
and the comments I received from them and an example (which they say its not perfect but just take a
look at it ) to see what they ask. They like to have figures and numbers in essay and they do not like
references normal internet sources, organizations, etc. more they prefer from PubMed, Google
scholar and Plos one, etc.
Dahlgren and whitehead Model is used (it is a must) for describing the problem. MALARIA in
count 2870 (excluding the footnotes)
ANC: Antenatal Care;
CDD: Community Drug Distributor
HIV: Human Immunodeficiency Virus;
IPT: Intermittent Preventive Treatment;
IRS: Indoor Residual Spraying;
ITN: Insecticide Treated Net;
MIP: Malaria in Pregnancy;
NGO: Non-Governmental Organization;
NMCP: National Malaria Control Program
PMI: Presidential Malaria Initiative
WHO: World Health Organization
Table of Contents
1.0 Introduction 3
2.0 Objective 5
2.1 Methods to be applied 5
3.0 Results 6
3.1 Age 6
3.2 Physiological differences 6
3.3 Unemployment-Poverty 7
3.4 Improper drainage facilities 7
3.5 General socio-economic, cultural and environmental conditions 7
3.6 Socio-economic conditions 7
3.7 Social- and community network 8
3.8 Risks brought about by farming methods 8
3.9 Geographical factors-Climatic and Environmental conditions 9
3.91 The People’s Understanding of the Dynamics of Malaria 9
3.92 Literacy level 9
3.93Intervention strategies to curb the spread of malaria 10
3.94 Insecticide Treated Nets 10
3.95 Home-based management of fever 11
3.96 Traditional healers 12
3.97 Intermittent Preventive Treatment (IPT) 12
3.98 Indoor Residual Spraying 13
4.0 Discussion 13
5.0 Conclusion 15
6.0 Recommendations 16
Malaria is responsible for more deaths than any other single disease in Uganda and thus remains the
leading cause of morbidity and mortality 1 . The relation between poverty and malaria has long been
recognized, but its paths are multiple and complex. The disease has had a crippling effect on the population
of Uganda and its economy for many years 2 .
Malaria is caused by Plasmodium parasites, which are spread to people through the bites of infected
Anopheles mosquitoes, the “vectors”, who bite mainly between dusk and dawn 3 . In most parts of Uganda
temperature and rainfall are sufficient to allow a stable, year round malaria transmission at high levels, with
relatively little seasonal variability 4 . More than 90% of the nation is highly endemic and more than 50% of
the population experiences high transmission levels of 50 or more infective mosquito bites per person per
year, the highest in Africa 5 . While pregnant women and children under five years are particularly
vulnerable, all people living in Uganda are at risk of being infected with malaria parasites and suffering from
the resulting illness 6 .
Uganda’s population was estimated to be about 30.7 million, with slightly more females than males.
A vast majority of 85% live in the rural areas 7 . In 2000 it had about 6 million malaria cases, increasing
1Shapiro, A. E., Tukahebwa, E. M., Kasten, J., Clarke, S. E., Magnussen, P., Olsen, A.,&Brooker, S.
Epidemiology of helminth infections and their relationship to clinical malaria in southwest Uganda.
TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE, 99(1), 18-
2Government of Uganda. Welcome to malaria control program of Uganda, Ministry of Health
online[retrieved 18 Dec. 2012].
3WHO (2012) WHO Malaria fact sheet N.94 [Internet].2012. [retrieved 18 Dec.2012]
4Pullan, R., Bukirwa, H.,,Staedke, R., Snow,. R and Brooker,. S. plasmodium infection and its risk factors
in Eastern Uganda. MALARIA JOURNAL 4 Jan 2010
5The Global Malaria Action Plan, [Internet] Roll back malaria partnership [reterieved 27.dec.2012].2008.
Njama‐Meya, D., Kamya, M. R., & Dorsey, G.Asymptomatic parasitaemia as a risk factor for symptomatic
malaria in a cohort of Ugandan children. TROPICAL MEDICINE & INTERNATIONAL HEALTH, 9(8), 862-
7Uganda Bureau of Statistics . Uganda National Household Survey (2009/2010) Socio-Economic Module.
ABRIDGED REPORT. November 2010, Kampala
dramatically to 16 million cases in 2005 and reducing to about 13 million cases in 2010 8 . See figure 1.
Figure 1a and b, Reported Malaria actual and suspected cases between the year 2000 and 2010.
Fugure 1a represents the actual malaria incidences reported in the country while figure 1b indicates
the suspected malaria cases across different ages per 1000 suspected cases. As shown in figure 1a, reported
malaria cases were the highest in 2005 with more than 16000000 cases reported, these were followed by the
years 2009 and 2010 which reported 140000000 and 125000000 respectively. Concerning the suspected
Malaria cases in figure 1b, children under five years of age were more vulnerable compared to the rest of the
population. 2005 reported the highest number of children affected by Malaria with more than 500 cases
reported. People with more than 5 years were the lowest with less than 200 cases reported within 2002 and
8The Republic of Uganda. Ministry of Health. UGANDA MALARIA REPORT REVIEW REPORT 2001-
- Kampala, May 2011
The objective of this literature review is to assess the determinant factors of malaria in Uganda and
current strategies to decrease its impact and to advise a local Non-Governmental Organization (NGO) o the
best way forward. Basically the literature review seeks to ask the questions “Why is malaria so widespread
in Uganda” and also “What is being done about it?” and possibly “By whom?”
2.1 Methods to be applied
The review of literature was mainly dependent upon literature available online and published within
the last five years. Databases that were visited include: PubMed and Google Scholar.
Websites used were mostly those of the Ugandan Government for secondary statistical data and also
websites run by NGOs that are trying to combat malaria in Uganda. Key words that were used include
malaria, Uganda, age, sex, pregnancy, education, unemployment, healthcare, housing, sleeping habits, water
and sanitation, poverty, agriculture. Dahlgren and Whitehead’s Model is used to describe and discuss the
determinants of malaria in Uganda 9 . See Figure 2.
Figure 2: Key Malaria Determinants.
9WHO. Dahlgren G and Whitehead M. European strategies for tackling social inequities in health: leveling
Up, Part 2 [Internet] 2007. Copenhagen,
Figure 2 Dahlgren and Whitehead’s (1993) 6
Partial immunity is developed over years of exposure and while it never provides complete
protection, it does reduce the risk that malaria infection will cause severe disease 2 . Children under the age of
5 years do not have this immunity yet and constitute a vulnerable group with the largest share of malaria
related mortality in Uganda 10 . The mean malaria parasite prevalence rate in children under the age of 5
years in Uganda is 45% 5 .
3.2 Physiological differences
Given equal exposure, adult men and women are equally vulnerable to malaria infection 11 .
However, because of the changes in women’s immune systems during pregnancy and the presence of a new
organ (the placenta) with new places for parasites to bind, pregnant women lose some of their immunity to
malaria infection and therefore, are at more risk. Malaria infection during pregnancy can have adverse
effects on both mother and fetus, including maternal anemia, fetal loss, premature delivery and low birth-
weight infants 12 . According to Uganda’s Household Survey 2000 to 2010, the number of pregnant women
in Uganda has increased from 1.1 to 1.5 million per year 5 .
Unemployment is associated with a lack of income and therefore poverty, which increases the
burden of malaria. High unemployment rates and food insecurity is an important issue in Uganda, especially
10Government of Uganda. Uganda, Ministry of Health, Uganda Malaria Control Program. UGANDA MALARIA CONTROL
STRATEGIC PLAN 2010/11-2014/15. October 2009.Kampala
11WHO . Gender and malaria, [Internet] June 2007, [cited 12 Nov.2012]
12GFATM. Intermittent preventive treatment (ipt) of malaria in pregnancy. 2000.
in rural areas. About 35% of the population lives below the poverty line and unemployment rates increased
from 1.90% in 2007 to 4.20% in 2010 2 . Having insufficient funds makes it hard for one to afford the
treatment of the illness 13 .
3.4 Improper drainage facilities
Underdeveloped and poorly maintained sewerage drains may result in stagnant waste water and thus
as a breeding ground for malaria 14 . The chances of this are increased when one lives in a low income
neighborhood 10 .
3.5 General socio-economic, cultural and environmental conditions
3.6 Socio-economic conditions
The period of political turmoil in the 1970s and 1980s in Uganda led to a break down in the
provision of most social, health and educational services. Subsequently, from 1996 to 2000, Uganda’s
economy grew at the astronomical rate of 6.2% and the population at a rate of 2.9%. In the same period the
GDP per capita grew 2.6% per annum 15 .
Nonetheless, Uganda remains one of the poorest countries in the world, ranking 145 on the global
Human Development Index, with 31% of its people living below the poverty line 16 . Malaria most likely
contributes to that position, since the disease is estimated to decrease gross domestic product by as much as
1.3% in countries with high levels of transmission. Malaria accounts for 26% of the burden of disease in
Uganda. It is estimated that workers suffering infected with malaria can be incapacitated for 5-20 days 6 .
3.7 Social- and community network
13Teklehaimanot, K and Paola M. A .Malaria and poverty. Annals of the New York Academy of Sciences, 1136(1), 32-37. 2008
14Lindblade, K. A., Walker, E. D., Onapa, A. W., Katungu, J., & Wilson, M. L. Highland malaria in Uganda: prospective analysis of
an epidemic associated with El Niño. TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE, 93(5), 480-
15Government of Uganda. Knowledge attitudes and practice about malaria treatment and prevention in Uganda: A literature
review, FINAL REPORT, February 2004
16IPFRI. Malaria and Agriculture, International food policy, research institute.[cited 6Jan.2013].IFPRI DISCUSSION PAPER01233.
Community members’ attitude towards malaria as a disease is important in understanding their
health seeking behavior and use of preventive methods. The communities are supposed to motivate and
support community health workers (their tasks are explained in the healthcare system section). Evidence
from a study by Batega shows that 40% of health workers received some kind of assistance from the
community members in the form of taking a register to the health centre, lending bicycles to collect
medication or helping to carry severely ill children to the health center. However, a majority of 60% of the
health workers said that they had not received any kind of assistance from community members. Such
community behavior is an obstacle for the implementation of the strategies for preventing malaria 11 .The
effect of this attitude is demotivation of the community workers. The effect of this uncooperative attitude is
demotivation of the community workers.
3.8 Risks brought about by farming methods
Several aspects of agriculture, especially those involving irrigation channels and pools of water, have
been identified as a contributor to breading grounds for mosquitoes. The people working and living in
agricultural areas are directly exposed to mosquito bites, due to larval breeding and resting sites of
mosquitoes in irrigation channels and pools of water 12 . In Uganda 80% of the population is involved in
agricultural activities thus greatly amplifying the risk associated with malaria 7 .
3.9 Geographical factors-Climatic and Environmental conditions
The warm and humid climate 17 , deforestation, agricultural expansion and new small dams are cited
as environmental factors responsible for successive malaria epidemics and mosquito survival 18 . The
weather in Uganda and the river beds, pools of stagnant water, dams, 80% agriculture and15% deforestation
makes a suitable area for larvae, mosquitoes and malaria 19 .
3.91 The People’s Understanding of the Dynamics of Malaria
Knowledge about the factors that promote malaria about the home is greatly lacking and this means
that people continue to live in environments that encourage the breeding of mosquitoes and their entry into
the home. Houses with mud brick walls, thatched roof, large open eaves with small rooms and large
numbers of occupants were likely to have larger numbers of mosquitoes than those without these features.
43% of households use only one room for sleeping, which can facilitate the spread of diseases, because of
3.92 Literacy level
The ability to read grants one access to information. In Uganda, this literacy could mean the
difference between life and death literally. Statistical data available suggests alarming levels of illiteracy
among women. In 2009, 70% of the women in Uganda did not complete primary education. 96% of the
women with secondary and higher education knew the actual cause of malaria compared to 76% of women
without formal education. Sources of information concerning malaria used by women in rural area were
mainly the radio, neighbors and some by health workers 11 .
17Zhou, G., Minakawa, N., Githeko, A. K., & Yan, G.Association between climate variability and malaria epidemics in the East
African highlands. PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES OF THE UNITED STATES OF AMERICA, 101(8), 2375-
18 Community Shelters Uganda. Water and sanitation,
20 International Travel and Health,2010[Internet],Geneva,1 January 2010
3.93Intervention strategies to curb the spread of malaria
Some important questions that are answered in this section include the following, “What is being
done to stop the spread of malaria? Who is initiating such measures? Who are the main beneficiaries of these
3.94 Insecticide Treated Nets
Insecticide treated nets (ITNs) are recommended as a key intervention to protect population at risk of
malaria 9 . ITN supply has rapidly increased with the establishment of a viable commercial market along with
distribution through civil society and the public sector 10 . The cumulative number of valid nets rose to
9,775,000 in 2010, including a steep rise in 2010 as a result of the distribution of the 7.2million nets to
pregnant women and fewer than five, resulting in a coverage rate of 64% of the population 5 . See Figure 3.
Figure 3 ITN ownership in Uganda 2006-2010
Valid Nets as indicate in figure 3 above refers to those nets with four squares as compared to
rounded nets. In studies of ITN use in Uganda, a major reason for not using nets was cost 20 . Other cited
reasons included: difficulty in hanging the net, poor sleeping conditions and the discomfort it causes. Many
pregnant mothers buy the net much later during pregnancy and some keep the net for the newborn, thereby
receiving little benefit for the control of malaria in pregnancy outcome. Some research has indicated that
20Government of Uganda. National Health Policy: Reducing poverty through promoting people’s health. Ministry of Health. May
subsidized ITN programs face obstacles such as program staff distributing nets to friends and family and
abuse of program funds 11 .
3.95 Home-based management of fever
Studies in Uganda indicate that there is a high preference for home treatment of malaria, which is
achieved with the help of volunteer Community Drug Distributors (CDDs). The CDDs teach mothers to
identify symptoms of malaria and provide them with easy access to pre-packaged drugs called “Homapak”,
which contain chloroquine (CQ) and sulfurdoxine-pyrimethamine (SP) to treat one episode of malaria. Since
40% of Ugandans are illiterate, the packets are color-coded 9 . The home-based management system is
affected by many factors, including the availability of medicines and other supplies and the cooperation of
the communities with the CDDs 13 .
An associated challenge however is the fact that these volunteers only carry with them basic
knowhow and medication that may be of little help if the infection of malaria is acute. At the same time,
these volunteers get demotivated from time to time and this greatly hampers their work given the fact that
the nature of their work makes accountability and supervision secondary to their individual interests. The
fact that they make this form of treatment a favorite is that it is significantly cheaper than accessing
conventional healthcare 21 . There are no consultation fees, the drugs are free and the transport element is
also omitted. Quality however takes a back seat despite the advantages.
3.96 Traditional healers
Lack of finance at the time of recognizing the illness, long distances to the health unit, lack of
knowledge about malaria symptoms and drugs often lead to self-medication and/or resort to traditional
healers 11 . Approximately 60% of Ugandans seek care from traditional healers before visiting the formal
21Government of Uganda. Ministry of Finance.Poverty Status Report. Economic Development Policy and Research Department,
3.97 Intermittent Preventive Treatment (IPT)
IPT is based on the assumption that every pregnant woman living in areas of high malaria
transmission has malaria parasites in her blood or placenta, whether or not she has symptoms of malaria. It
involves the administration of full curative treatment doses of an effective anti malarial drug at predefined
intervals during pregnancy, beginning after 16 weeks or quickening.
In Uganda the provision of IPT services largely depends on the availability of Antenatal Care (ANC)
services at health units 9 . The proportion of pregnant women that take at least 2 doses of IPTp-SP rose from 0
in 2001 to 18% in 2006 and 32% in 2009, whereas knowledge about IPTp-SP among pregnant women rose
from 0 in 2001 to 36% 2009 5 . See Figure 4. 47.5% Of health units reported frequent stock outs of SP for
IPT. Not providing IPT services include: inadequate support supervision and staffing at health facilities,
lengthy and bureaucratic public procurement programs causing stock outs, transport and allowances 9 .
Figure 4 MIP achievements 2001-2010 5
3.98 Indoor Residual Spraying
IRS is considered to be a cost effective public health intervention, given its ability to protect a large
number of people for relatively low cost of spraying. However, the little available research in Uganda
indicates that coverage levels for use of IRS are very low and only in initial stages of development. The
primary reason indicated for the low use of IRS was unavailability of funds, lack of information on
availability of IRS and lack of adequate and trained manpower in public and private sector to offer the same
service 11 . All of these measures are indeed noble in their nature; however the question that then begs
following all of these initiatives include “How much does it cost?” “Is there a real measurable benefit of any
of these methods?” and also “Are these some methods that need to be done away with?” such an appraisal is
crucial in determining the suitability of existing strategies to the country’s malaria situation.
Malaria as a ‘poor man’s disease’ have taken many lives in the perspective of Uganda. Pregnant
women and children under five years of age are the most vulnerable population in this respect. Illiteracy and
low level of education is related mostly linked to poverty, which a key determinant for the prevalence
malaria in this part of the world. In addition, the prevailing cultural beliefs, and gender related dynamics
among the populace tend to make these people belief in self-care and consultation of traditional healers, thus
negligence appropriate health care 19 . The weak healthcare system, long distances to health facilities,
improperly trained and unmotivated CDD’s and lack of necessary resources have presented challenges in
the fight against malaria. It is therefore crucial that attention be given to improving housing – and sanitary
conditions and access to safe water, especially in rural areas. IRS has achieved good impact on malaria
burden in target districts, but it is only implemented in few areas. There is a need for a rapid scale up of IRS
to achieve universal coverage. The introduction of IPT and ITN programs in ANC marked a turning point in
Uganda’s fight against malaria. However stock outs and/or the non-stocking of SP in ANC services, even
when available in health facilities, has hindered the implementation of IPT. Routine distribution of ITN’s
through ANC remains limited, therefore there is also a need to scale up routine ITN and SP distribution to
all pregnant women 14 .
The cliché which states that Prevention is better than cure is highly applicable to malaria, a disease
that ravages many third world nations. This study has provides pointers regarding the effect which the
disease has on the people it infects and this consequently has a negative effect on a country that already has
so many problems. This is because treating it is quite an expensive affair and this consequently implies that
prevention efforts have to be stepped up tremendously. A challenge that stakeholders in Uganda’s healthcare
have to contend with is the fact that many of the risk factors that encourage the spread of the disease are
present in abundance 20 . Living conditions of the population as well as their lack of appreciation for malaria-
prevention knowledge only serve to encourage the continued increase in infection. There is also a strong
correlation between malaria and economic status of the Ugandans, the high number of unemployed people
therefore signifies a higher rate of infections. However there are measures that have been taken to combat
the spread of this disease. These are sourced mainly from the government and the existing Non-
Governmental Organizations that have taken to combating the illness through the distribution of medication,
treated nets and also sensitization efforts. However, these efforts need to be increased, stepped up and
diversified if there is to be any chance of winning the war against this pandemic.
Among the determinants of Malaria infection in Uganda as identified in this study include age,
gender, poverty level, poor sanitation, lack of community network to enhance health operations, lack of
awareness by the people concerning the general issue of malaria and illiteracy. It would be therefore, be
important for the government to deal with each of these factors if they are serious about overcoming this
problem in the country.
The bodies that are responsible for efforts to curb the spread of Malaria in Uganda should formulate
strategies that are targeted at the different segments of the population with relevance to the risk they
A higher proportion of the resources needed in this fight such as drugs and nets should be targeted at
women who are expectant and also children below five years of age.
With regard to the other demographics such as poverty and also the type of housing that the people
are living in, it will be necessary to prioritize efforts aimed at those who live in low-income housing
areas where the materials and the dimension of the housing structures increase the spread of malaria
This should be in regard to the budgetary allocations and also the man-power requirement of the
program. This way, the efforts will be efficient in regard to their reach.
Once the most at risk persons have been accounted for, efforts such as the distribution of free
Insecticide Treated Nets needs to be conducted.
With regard to priority and emphasis, it will be very important to empower the people with matters
concerning their healthcare.
It is also paramount that the authorities find means of motivating health workers through such
Factors as better pay, incentives, leave and so on. They should also leverage the challenges which
they go through in order to enhance their workability.
Empowerment of the population may include introducing of literacy programs to illiterate people,
creating awareness on malaria and how to prevent and fight back and we said earlier, creating
income generating opportunities for people who have none. These will be very effectively measures
to deal with this epidemic.
The authorities should as well increase the health destinations for more people to access health
facilities. This is because in Uganda, may people especially those living in rural areas have to travel
long distances in search of healthcare. This is what makes most of them to look for alternative means
in form of traditional cures.
List of Works Cited
- Shapiro, A. E., Tukahebwa, E. M., Kasten, J., Clarke, S. E., Magnussen, P., Olsen, A.,& Brooker, S.
Epidemiology of helminthes infections and their relationship to clinical malaria in southwest
Uganda. TRANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND
HYGIENE, 99(1), 18-24. 2005.
- Ministry of Health, Uganda. Welcome to the Malaria Control Program of Uganda, Ministry of
Health online. 2007.
- WHO . WHO Malaria fact sheet N.94.2012
- Pullan, R., Bukirwa, H.,,Staedke, R., Snow,. R and Brooker,. S. Plasmodium infection and its
risk factors in Eastern Uganda. Malaria journal 4 Jan 2010.
- The Global Malaria Action Plan. Roll Back Malaria Partnership. 2004.