Uganda Public Health Fellowship Program’s Contributions to Malaria Control Programs 2015–2022: Strategies, Implementation Challenges, and Opportunities

Coordination of Malaria Epidemic Response

Before UPHFP existed in Uganda, response to epidemics was not well coordinated and outbreak investigations were frequently conducted in administrative silos by different departments of the MOH. Since the commencement of the UPHFP, there have been significant improvements in the coordination and implementation of outbreak investigations and response in Uganda.

UPHFP fellows are members of the National Rapid Response Team during emergencies and outbreak investigations, including malaria outbreak investigations. Outbreak reports prepared by fellows are routinely discussed in the National Public Health Emergency Operation Center and presented at the National Task Force for Epidemic Preparedness and Response, which provides guidance and oversight to disease outbreak prevention and control in the country. For example, in 2021 and 2022, multiple malaria outbreak investigations by fellows informed strategic decisions for the malaria program. A notable example includes the 2018 outbreak report on blackwater fever cases (a severe complication of malaria). This report, combined with follow-up case-control studies, have informed decisions by the National Malaria Control Division of the MOH to: a) update Uganda clinical guidelines by including the diagnosis, clinical presentation, and management of blackwater fever; b) prioritize blackwater fever for emergency response in the malaria strategic response plan; and c) select districts to prioritize for introduction of the malaria vaccine in Uganda.

Although the Government of Uganda has made notable progress in strengthening political commitment to prevent and control public health emergencies, challenges remain in the timely release of domestic funds required for rapid epidemic response, including malaria outbreaks. Since its inception, UPHFP, supported by the US Government, has helped bridge these gaps by enabling rapid access to resources and deployment to affected areas during emergencies. However, under the current America First Global Health Strategy, which reorients US global health assistance toward multiyear bilateral agreements focused on strengthening local health systems, reducing inefficiencies, and promoting sustainability, the mechanisms for disbursing funds to UNIPH will change, although the overall funding level is not expected to be significantly affected in the short term.

Malaria Surveillance and Early Warning System

Before UPHFP, the MOH did not have an active malaria epidemic alert system to aid the detection of malaria outbreaks. In 2016, UPHFP fellows created such a system to monitor malaria “normal channels” (normal thresholds) using existing data in real time and identify upsurges as soon as they occur. Early detection is crucial for containing outbreaks before they escalate into larger public health crises. To confirm the existence of a malaria upsurge at an early stage, the fellows compared weekly malaria cases to the expected number of cases for a particular district during a similar period of the year based on data from the previous 5 complete years. The system created by the UPHFP fellows allowed for the early detection of 14 malaria outbreaks until 2022 and enabled the team to respond and initiate timely preventive and/or control measures.

On a weekly basis, UPHFP fellows review and analyze malaria surveillance data to assess the malaria situation, the performance of the surveillance system, and to guide necessary response(s). The fellows also create feedback mechanisms from the central to lower levels of the health system by generating a weekly malaria bulletin (Table 2). The bulletin has been running regularly since 2015, with fellows taking the lead in its production. The bulletin has enabled the MOH and its partners to devise strategies to address obstacles to malaria control. For example, a recent evaluation of malaria epidemic alert thresholds (“malaria normal channels”) has informed redefining what constitutes malaria epidemics, and a report on risk factors for deaths among children with severe malaria in the district of Namutumba informed strengthening of community malaria death surveillance. More so, the bulletin is disseminated to district health officers who use the report to monitor stock levels of essential supplies like antimalarials, ensuring timely redistribution to areas with shortages.

Several impact evaluation projects have been conducted by fellows to inform policy (Table 2), including a study that assessed the impact of IRS on the incidence of malaria among children under 5 years old.⁷ This study showed that, following IRS in November and December 2015, malaria incidence dropped for 6 months, after which it started increasing until an epidemic was declared in June 2015, right after a peak in rainfall. Authors of the study recommended that IRS be rescheduled to coincide with the build-up of vector populations just before the onset of the peak transmission season, rather than introducing it anytime when IRS insecticides become available. Since then, the recommendations have been adopted.

Other studies conducted by the fellows have provided similarly valuable insights. For example, investigations into malaria outbreaks driven by rainwater harvesting and roadside pools revealed the role of environmental factors in sustaining mosquito breeding. These findings informed recommendations for targeted vector control interventions, such as reducing breeding sites in addition to conventional tools like insecticide-treated nets and IRS. Furthermore, the rainwater harvesting study led to community-level educational initiatives to mitigate the unintended consequences of water storage practices, demonstrating the program’s ability to influence both policy and grassroots-level behavior change.

Teaching and Mentoring

UPHFP fellows trained and developed the capacity of District Health Teams (DHTs) in activities related to their expected tasks (Table 2), including analyzing surveillance data and developing visualizations to improve malaria data use. Other capacity-building activities included training DHTs in epidemic-prone districts on how to establish the Malaria Epidemic Early Detection System (MEDS) for timely detection of malaria epidemics. The MEDS uses malaria surveillance data to develop malaria epidemic alert thresholds (“malaria normal channels”).⁸ The malaria normal channels help the DHTs to detect outbreaks and deploy timely interventions to prevent or mitigate the scope and impact of epidemics on the population.

UPHFP fellows are also directly involved in the mentorship and training of Field Epidemiology Training Program (FETP)-Frontline trainees (Table 2). The FETP-Frontline is a 3-month in-service training program to strengthen epidemiological capacity at the district level and focuses on the detection of and response to epidemic-prone diseases at the source. Participants come together for 3 classroom workshops; between workshops, FETP-Frontline participants return to their jobs and complete field projects to practice, implement, and reinforce what they have learned. Mentorship of FETP-Frontline trainees is critical in the production, interpretation, and updating of malaria normal channels as well as other surveillance activities.

Public Health Communications

UPHFP published 8 malaria-related articles in peer-reviewed journals^6,7,9–14 and 20 articles in the UNIPH quarterly epidemiological bulletin by December 2022 (Table 2). In addition to the manuscripts, PHFP has had several malaria-related abstracts accepted for presentation at national and international conferences.

UPHFP fellows have developed and delivered oral public health communications and conducted risk communication activities to spread awareness and combat misinformation about malaria in Uganda, including engaging communities through social media, radio, press interviews, and public awareness campaigns. Some newspaper articles, such as “Why the fight against malaria should continue in Uganda,”¹⁵ were published in the national newspaper. The article highlighted the population at risk of poor outcomes of malaria and how the population can prevent malaria.

Management and Leadership

UPHFP fellows and graduates have held leadership positions in a variety of MOH departments. For example, supervisors and coordinators at the UNIPH as well as program leads at the MOH include several graduates of UPHFP, some of whom continue to provide valuable contributions to malaria control in the country. FETP fellows were also involved in the planning and coordination of activities in the MOH National Malaria Control Program, serving as subject matter experts in risk communication, monitoring and evaluation, statistical analysis, and grant writing. UPHFP fellows participated in the writing of a Global Fund concept note, which enabled the government to obtain funding for the 2024–2027 Global Fund grant for malaria. The concept note writing process is a critical activity led by the MOH, as it secures funding for national health programs, including malaria control efforts. The fellows contributed to key areas, including statistical analysis, monitoring and evaluation, and drafting technical sections of the concept note.

Quality Improvement and Policy Briefs

According to the WHO framework for quality of care,¹⁶ health systems should endeavor to improve in 6 essential areas: efficacy, efficiency, accessibility, acceptability, equity, and safety. With a focus on enhancing the quality and effectiveness of health systems in these priority areas, UPHFP fellows carry out quality improvement projects (Table 2). One such project on the malaria treat-and-track policy included mapping gaps within the continuum of care and making recommendations to address the gaps.

UPHFP fellows’ policy papers on malaria have compiled research evidence and provided recommendations on potential courses of action based on knowledge gained from various situations. For instance, a policy brief on combating pesticide resistance (Table 2) summarized evidence for increasing insecticide resistance and emphasized the urgency of using synergist piperonyl butoxide (PBO)-enhanced mosquito nets to combat insecticide resistance. These briefs were specifically targeted at decision-makers within the MOH, the National Malaria Control Program, and implementing partners, with the aim of informing and improving malaria control policies.