Background: The private sector provides about half of all health services in Uganda. The private sector can therefore be a barrier or facilitator to ensuring that suspected malaria cases receive confirmatory testing, and confirmed cases receive appropriate treatment. National malaria outlet surveys conducted between 2010-2013 documented private sector scale-up in availability of malaria testing and quality-assured artemisinin combination therapy (QAACT).
Methods: A 2015 national malaria outlet survey included a fever case management component to measure private sector testing and treatment for fever patients. A census of public and private outlets with potential to distribute malaria testing and/or treatment was conducted among a representative sample of administrative units. In total, 3,483 private sector outlets (private health facilities, pharmacies and drug stores) were screened for availability of malaria testing and treatment, and an audit was completed for all antimalarials, malaria rapid diagnostic tests and microscopy. Where testing and ACT treatment were available, screening identified patients seeking treatment for uncomplicated illness with fever. Consultation observation and exit interviews were conducted with 1,273 eligible fever patients within 1,089 private sector outlets.
Results: In a nationally-representative 2015 outlet survey, 1 in 4 private sector outlets had both confirmatory testing and QA ACT treatment available. Among outlets with testing and treatment available, study results suggest positive private sector performance with respect to testing all fever patients, particularly in health facilities and drug stores, however testing was very low in pharmacies. Not all patients seeking treatment in the private sector can or will be tested for malaria. This is because some patients are not present for the consultation (about 1 in 4, including half of patients presenting at pharmacies). Additionally, some patients sought treatment for their fever before seeking treatment at these private sector outlets, and in some cases they had already received a malaria test. Patients who tested positive for malaria usually received antimalarial treatment, however only half received QA ACT. In summary, results show that in many instances, private providers who stock ACT and malaria testing often use available commodities to appropriately manage patients. However, gaps persist in ensuring all fever patients receive a confirmatory test and QA ACT. There is need to further promote confirmatory testing and first-line ACT treatment among patients and private sector providers, as well as discourage the use of non-artemisinin therapies and inappropriate use of injectable artemisinin monotherapies for uncomplicated cases.