Indoor residual spraying (IRS): The magic bullet for malaria elimination in Uganda

By Chrispus Mayora

In Uganda, approximately 16 million malaria cases are reported, and over 6,000 deaths annually. Imagine, every day, up to 16 people die in Uganda, as a result of preventable Malaria!

This statistic makes Uganda the 9^th highest malaria burden country in the world. In fact, the burden of malaria is higher than HIV/AIDS, yet malaria has not received as much attention as HIV/AIDS in Uganda.

It is estimated that every Ugandan gets an average 2.5 episodes of malaria per year. It is also estimated that malaria contributes up to $200 million annually in lost income to the economy.

This is through lost productivity from absenteeism due to sickness, lost time for family members taking care of their sick, etc. To this, add direct costs to the household for medical care, hospitalization and lodging related costs, transports, food, etc.

This directly or indirectly impacts on Uganda's economy and development in general. From estimates done by the SPEED programme at Makerere School of Public Health, if government was to provide malaria treatment with - Coartem, at the subsidised price (sh3,500) provided by the Global Fund in Geneva, about sh306b will be consumed for just one year. 

Without the subsidy, buying Coartem would exhaust an entire sh1.8 trillion for malaria treatment alone. This is virtually the budget allocation to the Ministry of Health. From these statistics, it is apparent that addressing the malaria challenge alone would not only save the economy huge resources that can be invested in other pressing areas, but would also free enough resources for the health sector that would foster reallocations to other critical service areas.

A lot of work focused on addressing the malaria pandemic in Uganda has been championed by the Malaria Control Program (MCP) of the Ministry of Health, with support from implementing partners. The focus has been majorly in distribution of Insecticide Treated Nets (ITNs) to households, coupled with behavior change communication to stimulate their effective use. Indeed commendable successes have been recorded on this front with recent statistics showing that more than 90% of households in Uganda have received a mosquito net. Looking at this statistic, and then reflecting on the continuous burden of malaria, the questions one cannot miss to ask are: is the distribution of ITNs an optimal strategy that will address this challenge?

Are the ITNs effectively utilized as recommended so as to offer optimal protection? Are there other strategies that may currently not be implemented yet may be more effective than ITNs? In a dissemination meeting organised by the SPEED programme at Makerere School of Public Health, in collaboration with a Health Consumers' Protection Organization (UNHCO), attended by different stakeholders including Uganda Parliamentary Forum on Malaria (UPFM), Ministry of Health, WHO, and Civil Society Organizations, the answers to these questions seemed apparent. Ministry of Health can only regulate distribution, but their use within homes is essentially out of their control.

The major assumption can only be that households are effectively using ITNs as recommended. However, in many circumstances, it is reported that perceptions, information and (mis)conceptions about ITNs do influence their use. Additionally, recent research shows that mosquito bites are in most cases encountered even before individuals retire to their bed nets.

People have longer stays outside due to several outdoor activities - cooking, evening parties and leisure activities - and by the time they apply a bed net, it can no longer offer the much needed protection. It is clear from these arguments that no matter how much coverage of ITNS we strive to achieve as a country, we may not address the malaria challenge.

We need to rethink the strategic interventions to focus on. Given its propensity to overcome behavioral antecedents that affect effective use of ITNs, vector control through IRS is a major strategy through which malaria can be drastically reduced. With IRS, mosquitos often hanging around walls of the house, waiting to bite (infect) before the ITN takes full control, are sprayed and eliminated. Indeed studies in many countries and settings have shown that Indoor residual spraying (IRS) is the most effective, and economical approach to address the malaria pandemic in the communities. Yet, the Uganda Malaria Control Program has not prioritized this strategy.

For instance, indoor residual spraying (IRS) has only financed in less than 20 districts (out of 112) despite this being the most effective way to reduce malaria across the country.

Even this limited IRS coverage has been funded by donor support, with very limited contribution from government resources, which in itself exposes the program to the vagaries of aid (un)predictability. Given the limitations of government revenues and the ever-declining allocations to health, it is prudent to prioritize the financing of interventions that have been proven to be "best-buys" for resources.

While the coverage of ITNs is commendable, it is reasonable to argue the ministry to Health to reconsider effective implementation and scale-up of mass Indoor Residual Spraying (IRS), as an already proven cost-effective strategy to eliminate Malaria in Uganda, once and for all. A Malaria-Free Uganda population is a citizens' right. Let's act together to achieve this!

The writer is a lecturer and health economist with SPEED - Makerere University School of Public Health