On October 10, Mr Pius Kisekka woke up with spells of cold chills and a high fever. He was quick to withdraw some money from his mobile money account and head to a nearby private clinic in Kawempe Division, a Kampala city suburb.
"I suspected that I had malaria based on the symptoms, but the doctor insisted they conduct confirmatory tests and other laboratory tests," the 47-year-old father of five recollects.
Mr Kisekka's suspicion turned out right when he was diagnosed with severe malaria.
But the self-employed mechanic was shocked by the bill after years of not being infected with the disease.
"I had to pay Shs120,000 exclusive of consultation fee yet I only had half of the total bill. I had to borrow some money from a friend," he narrates.
Ms Ruth Asiimwe, 29, a resident of Makindye Division, also faced a similar financial hardship when she spent nearly all her August and October salaries treating herself and daughter for malaria.
"I was diagnosed with the disease twice in one month and each time I had to part with more than Shs100,000 at one of the private clinics in Kampala," Ms Asiimwe says.
"I was yet to see the worst. My seven-year-old daughter was also diagnosed with malaria a month later and I had to part with the same amount again," she adds.
The two cases underline the financial challenges faced by many Ugandans who seek malaria treatment in private health facilities.
Although they are more convenient than public health facilities that offer free treatment but face recurrent stock-outs and long waiting hours, patients pay highly for the services.
More people are weighed down by the financial burden given the current upsurge of malaria in the country, which has affected more than 65 districts due to the rainy season.
The Ministry of Health confirmed that the upsurge started in August 2018 before peaking in June this year.
Experts have attributed the increased cost of treatment to changes in the way the parasite causing malaria behaves and the adherence to medicine.
Dr Jonathan Kayondo, a clinical epidemiologist at the Uganda Virus Research Institute (UVRI), who has done several years of research on malaria, says people are most affected by the cost when there is a recurrence, especially in periods of upsurge.
"If you get treated and recover, it does not mean you are protected for life. It takes seven to 14 days after you have been bitten by the infected mosquito for symptoms to show depending on the species of the mosquito. So even if you take the treatment, you can still catch malaria," Dr Kayondo says.
Doctors in private health facilities have also indicated that drug resistance and a patient's choice have played a crucial role in increasing the cost of treating malaria.
"It is true the cost is high because malaria is now resistant to [some] drugs and the alternative ones are more expensive. Quinine intravenous drug and injections are more effective but much more expensive," Dr Vincent Karuhanga, the proprietor of PolyClinic in Kampala, says.
There has been a long history of resistance to antimalarials in Africa and Uganda has not been an exception, where at one time, chloroquine was the leading recommended treatment against malaria.
Resistance to chloroquine devastated the fight against malaria, resulting in several malaria deaths because the drugs no longer cured malaria reliably.
As a result, the World Health Organisation (WHO) recommended artemisinin combination therapy (ACT) drugs, such as coartem (artemether-lumefantrine).
Dr Karuhanga also says such intravenous drugs drain sugars from the body, therefore, a patient has to be put on sugar drips for two or three days, making treatment very expensive. However, the patients' choice can also make the price very expensive, according to Dr Timothy Luganda, the operator of Capital Centre Private Clinic in Bwaise, Kawempe Division. Dr Luganda says people always opt for the best drug which is also easy to administer like the artesunate intravenous dose. It is given after 12 hours compared to quinine, which is given after every four hours and requires one to be admitted.
"A bottle of quinine costs Shs2,000 at pharmacy price and the whole dose, which can be administered on an adult goes for Shs60,000 or Shs50,000, unlike artesunate whose cost is at Shs120,000," Dr Luganda says.
He adds that choice also applies to tablets such as coartem. Patients complain that it is hard to take it four times a day yet there are other oral drugs which are taken fewer times a day.
"A dose of six antimalarial tablets, for example, costs between Shs15,000 and 20,000 while coartem of 24 tablets a dose costs Shs5,000," Dr Luganda says, adding that patients wrongly use the drugs and don't complete the doses thus causing reoccurrence of the disease.
"And when it [malaria] happens, you cannot go back to that drug," he adds.
Malaria is still the leading cause of illness for all ages of all outpatient department attendances and admissions, according to statistics from the latest Health ministry sector review report.
The report indicates that malaria accounts for 12.5 per cent of all the outpatient attendances and is still the leading cause of admissions for all ages.
However, the financial burden of treating malaria has also affected government as it has to spend more to treat the public.
Dr Jimmy Opigo, the programme manager at Malaria Control Programme at the Ministry of Health, says government currently spends $100m (about Shs370b) due to the current upsurge yet the cost had reduced by one per cent two years ago due to the high investment in preventive measures such as mosquito nets and indoor residual spraying.
Dr Opigo also says the cost of malaria treatment includes working days, cost of transport, number of tests, consultation and anti-malarial drugs administered.
"The cheap medicine is the one we subsidise. That is the green leaf which is our first line," Dr Opigo says, adding that there is currently no résistance in the country against the drugs but there are some treatment failures.
Treatment failure, according to Dr Opigo happens as a result of quality problems or compliance or dosing or within a short period get reinfection like Mr Kisekka's case
Dr Opigo says sometimes a dose is supposed to protect one for a month but sometimes it does not last due to poor adherence.
To reduce the financial burden, Dr Opigo advises families to invest in preventive measures such as sleeping under mosquito nets and spraying their houses which cost less than the treatment.
Malaria cases on the rise
Malaria, which is caused by a female anopheles mosquito, has become a perennial problem despite various government interventions, including indoor residual spraying and mosquito nets distribution. The World Malaria Report 2018 indicated that Uganda registered an estimated increase of more than 100,000 malaria cases between 2016 and 2017 despite the various preventive interventions against the disease. The report also indicated that the country accounts for 4 per cent of malaria cases in the whole world, ranking it among the top five. The findings indicate a backslide given that the latest Uganda Malaria Indicator Survey 2014-15 had indicated that the national malaria prevalence dropped from 42 per cent in 2009 to 19 per cent.
In April, scientists announced that they had developed a new anti-malaria drug to boost the fight against malaria. Pyramax, which was developed by Shin Poong Pharm, a Korean company, stays in the body for a long time thus protecting the patient for an extended period. Mr Bob Peter Okello, the country manager of Shin Poong Uganda, said a number of clinical trials were carried out and proved that the drug is efficient in the treatment of uncomplicated malaria.