{"id":175736,"date":"2025-11-11T23:02:13","date_gmt":"2025-11-11T23:02:13","guid":{"rendered":"https:\/\/www.europesays.com\/ie\/175736\/"},"modified":"2025-11-11T23:02:13","modified_gmt":"2025-11-11T23:02:13","slug":"the-24-2-hours-initiative-a-game-changer-in-malaria-mortality-reduction-malaria-journal","status":"publish","type":"post","link":"https:\/\/www.europesays.com\/ie\/175736\/","title":{"rendered":"The 24, 2 hours initiative: a game changer in malaria mortality reduction | Malaria Journal"},"content":{"rendered":"

The Global Technical Strategy for Malaria calls for at least a 75% reduction by 2025 compared with 2015 [1<\/a>]. However, the global tally of malaria deaths reached 597,000 deaths in 2023 compared to 586,000 in 2015 [2<\/a>, 3<\/a>]. In 2023, Uganda reported approximately twelve million malaria cases and 2793 deaths and was the third-largest contributor to global malaria cases and the tenth-largest contributor to malaria-related deaths [3<\/a>]. Severe malaria represents approximately 15\u201320% of hospital admissions in the country [4<\/a>]. In 2023, Uganda recorded about 700,000 hospitalized malaria cases, accounting for roughly 6% of the total malaria burden. This is nearly three times the global average [3<\/a>], noting that the global figure indicates between 1 and 3% of uncomplicated malaria cases were assumed to have moved to the severe stage of disease, and 50\u201380% of severe cases were assumed to have been hospitalized [3<\/a>, 5<\/a>]. Moreover, Health Malaria Information System (HMIS) data of Uganda indicates that 5\u20138% of children discharged (depending on age) will die within 6\u00a0months of discharge and most of these deaths occur at home.<\/p>\n

The important queries are why hospitalization rate of malaria cases in Uganda is high, and what are the malaria deaths drivers?<\/p>\n

Delayed treatment of uncomplicated malaria cases is a major contributor to disease progression to severe form that as medical emergency needs urgent inpatient case management services [6<\/a>, 7<\/a>]. Consequently, severe malaria may result in complications, or death. Literature confirmed that seeking health care within 24\u00a0h of onset of illness is a serious gap in Uganda [8<\/a>,9<\/a>,10<\/a>]. Moreover, delays in initiating injectable artesunate in severe malaria cases and delays in managing severe malaria complications significantly contribute to malaria deaths in the country [11<\/a>].<\/p>\n

A total of eleven African countries, including Uganda, account for about 68% of malaria deaths that are part of the \u201cHigh Burden to High Impact\u201d (HBHI) initiative aimed at accelerating progress against the disease [3<\/a>]. In March 2024, ministers of health from the HBHI African countries committed to ending malaria deaths in the Yaound\u00e9 Declaration [3<\/a>]. In line with the Yaound\u00e9 Declaration, Uganda launched the \u201c24.2 Hours Initiative\u201d in April 2025 to strengthen malaria case management services and to address drivers of delayed treatment (Fig.\u00a01<\/a>).<\/p>\n

Fig.\u00a01<\/b>\"figure<\/a><\/p>\n

Launching ceremony of the \u201c24,2 Hours Initiative\u201d, April 2025. https:\/\/www.afro.who.int\/countries\/uganda\/news\/ugandas-242-hours-initiative-game-changer-malaria-mortality-reduction<\/a>)<\/p>\n

This perspective article presents existing evidence in the literature covering both malaria case management gaps in Uganda as well as relevant solutions to achieve reduction of malaria mortality and accordingly proposes a\u00a0strategic framework\u00a0called the \u201c24,2 Hours Initiative\u201d. The principles guiding the initiative may be applicable to other high-endemic regions, including sub-Saharan Africa, if they are adapted into locally tailored interventions.<\/p>\n

Continuums of malaria case management services<\/p>\n

Malaria case management, consisting of quality assured early diagnosis and prompt effective treatment, remains a vital component of malaria control and elimination strategies [12<\/a>]. Malaria case management as a key part of universal health coverage should be available throughout the country and to everyone [1<\/a>, 3<\/a>, 12<\/a>]. Malaria case management services should cover following patient categories: suspected malaria, confirmed uncomplicated malaria, severe malaria and discharged severe malaria patients from hospital. This category forms the basis of the \u201c24,2 Hours Initiative\u201d (Fig.\u00a02<\/a>).<\/p>\n

Fig.\u00a02<\/b>\"figure<\/a><\/p>\n

Targeted patients of malaria case management services<\/p>\n

Review of Uganda malaria case management<\/p>\n

This section presents the World Health Organization (WHO) recommendations and literature findings regarding gaps in Uganda malaria case management strategy as well as lack of adherence to WHO and national guidelines.<\/p>\n

Suspected and confirmed uncomplicated malaria<\/p>\n

The WHO emphasizes on prompt and appropriate diagnosis and treatment of uncomplicated malaria cases within one day of the onset of malaria symptoms [7<\/a>, 13<\/a>]. Nevertheless, evidence from the literature shows delayed healthcare-seeking, delayed treatment of malaria cases, and low treatment coverage in Uganda [8<\/a>,9<\/a>,10<\/a>]. Based on Uganda Malaria Indicator Survey 2019, only 57% of children under five with fever sought treatment within 24\u00a0h from the onset of fever and only 64% of children with fever, received any anti-malarial treatment [14<\/a>]. Across different studies, delays in receiving malaria treatment beyond 24\u00a0h from symptom onset ranged from 41% to about 80% [8<\/a>, 9<\/a>, 14<\/a>], with longer delays observed in rural areas [14<\/a>]. Unfortunately, rate of prompt treatment within 24\u00a0h in many African countries is also low [14<\/a>, 15<\/a>], despite this fact that the people expose frequently to Plasmodium infections [15<\/a>].<\/p>\n

Additionally, universal access to quality malaria care remains a challenge in Uganda. Over 50% of malaria cases are managed through the private sector or self-medication, largely due to overcrowded public health facilities and frequent stockouts of essential antimalarial drugs [16<\/a>].<\/p>\n

Severe malaria<\/p>\n

Severe malaria is a medical emergency that requires urgent treatment. The WHO emphasizes that parasitological diagnosis should be made available to healthcare providers within two hours to ensure the appropriate choice of antimalarial drugs and dosing. To avoid delays in treatment, in suspected severe malaria cases where parasitological diagnosis is unavailable or delayed, the WHO recommends initiating treatment based on clinical suspicion [6<\/a>]. The WHO also recommends that where complete treatment of severe malaria is not possible, patients should receive a first dose of one of the recommended prereferral treatments, preferably via the parenteral route or if not feasible, for children under six years old intrarectally, unless the referral time is very short [6<\/a>, 7<\/a>, 12<\/a>, 17<\/a>, 18<\/a>].<\/p>\n

Delays in treatment of severe malaria cases in Uganda have been reported by the literature. Accordingly in the studies population, a range of 25 -71% of hospitalized severe malaria cases delayed initiating injectable antimalarial drugs by at least one calendar day [11<\/a>, 19<\/a>, 20<\/a>], and only 37% of the children with danger signs visited community health workers (CHWs) within 24\u00a0h of onset of illness [10<\/a>]. Additionally, reported proportion of eligible severe malaria cases who received a dose of prereferral rectal artesunate varied from 55 to 73% [21<\/a>, 22<\/a>].<\/p>\n

Discharged malaria cases from hospital<\/p>\n

The WHO recommends that children admitted to hospital with severe anaemia living in settings with moderate to high malaria transmission can be given a full therapeutic course of an antimalarial drugs at predetermined times following discharge from hospital to reduce re-admission and death [17<\/a>]. Administration of post-discharge malaria chemoprevention (PDMC) is endorsed in the national malaria treatment guidelines (NMTGs). While the prevalence of readmission with severe malaria among children under 5\u00a0years of age was reported around 27% [23<\/a>], but, based on HMIS, a majority of children were not administered PDMC.<\/p>\n

Adherence to WHO recommendations and national guidelines<\/p>\n

Adherence to WHO and the NMTGs recommendations in Uganda is sub-optimal [22<\/a>, 24<\/a>]. A study results showed that approximately one in three children under five with fever receiving substandard care [25<\/a>]. The literature has identified gaps in adherence to the NMTGs for both suspected and confirmed uncomplicated malaria cases. These gaps include delays in seeking care, incomplete treatment, self-medication, administration of antimalarial drugs without diagnostic testing, and the consumption of substandard or fake antimalarials. Substandard and fake antimalarials pose significant health and economic risks, disproportionately affecting poor and rural populations and contributing to health inequities in Uganda [26<\/a>, 27<\/a>].<\/p>\n

Poor adherence to treatment guidelines can lead to suboptimal health outcomes, diagnostic challenges, treatment failure, and irrational use of antimalarial drugs. Addressing these issues is, therefore, a top priority [24<\/a>, 28<\/a>,29<\/a>,30<\/a>,31<\/a>,32<\/a>]. Notably, more than 50% of malaria cases in Uganda receive treatment from private sector and drug shops. This is important given reported quality issues of case management services and poor adherence to the NMTGs in private sector was higher in the literature [25<\/a>, 33<\/a>,34<\/a>,35<\/a>,36<\/a>,37<\/a>,38<\/a>]. Studies results showed that drug shops frequently provided sub-optimal care, which contributed to inappropriate use of antimalarial drugs and delays in accessing appropriate treatment [34<\/a>, 39<\/a>]. Moreover, many private drug outlets clients receive antimalarial medicines without proper diagnosis or prescription, only a minority obtain quality-assured treatments, and the availability of non-WHO-prequalified artemisinin-based combinations has risen in recent years [38<\/a>, 40<\/a>].<\/p>\n

Quality issues is not limited to uncomplicated malaria cases. Study results confirmed that the quality and coverage of severe malaria case management services in health system in Uganda require improvement. Based on literature, fewer than the recommended three doses were administered in around one fifth and delays were common in around two third of severe patients [20<\/a>].<\/p>\n

Adherence to severe malaria treatment guidelines for children in regional referral hospitals has been reported as poor and requires improvement [20<\/a>]. Only 44.5% of severe malaria cases in Uganda received both a parenteral antimalarial drug and oral artemisinin-based combination therapy (ACT) [22<\/a>]. Besides, most severe malaria cases who received prereferral RAS did not receive appropriate after-referral treatment [41<\/a>]. Evidence from the literature shows that the effectiveness of pre-referral rectal artesunate in Uganda is limited by poor access to quality post-referral care [22<\/a>, 41<\/a>, 42<\/a>]. Additionally, many children with severe malaria do not complete either pre-referral or post-referral treatment, and referral compliance rates remain low [41<\/a>,42<\/a>,43<\/a>].<\/p>\n

The literature highlights the following drivers of suboptimal adherence and poor-quality services:<\/p>\n