Uganda

Background: Malnutrition and diarrhoeal diseases are common among children of Uganda. The situation is compounded by a high prevalence of HIV and malaria. Anaemia is also common and is attributed to malnutrition, iron deficiency and the high transmission of malaria. Zinc is the micronutrient which is limiting for most of these morbid conditions. Based on the seminal basic, clinical and programmatic research done primarily at ICDDR,B and few other centres, the WHO and UNICEF now recommend a 10 day course of zinc for each episode of diarrhoea. This is now part of diarrhoea treatment, the other integral component being oral rehydration salt solution.

The supplementation of zinc during a diarrhoea episode results in shorter duration of diarrhoea, fewer relapses over the next 6 months, and decreased mortality. Zinc, however, is not readily available in the Uganda. Syrup preparations imported from Pakistan and India, even if available in the medicine shops, are quite expensive. It is therefore important that zinc treatment be scaled up in Uganda. This should include the following steps:
 

• Revising national guidelines for the treatment of diarrhoea and malnutrition
• Creating awareness regarding the importance of zinc in child malnutrition and diarrhoea, including mass media campaigns (TV advertisements are going to impact on all East African countries)
• Revising the curricula to include the new WHO/UNICEF guidelines for management of childhood diarrhea
• Making available zinc preparations
• Dialogue with manufacturers of dispersible zinc tablets in Bangladesh for assessing the feasibility of manufacturing the tablets in Uganda or in the region (in collaboration with local pharmaceutical industries) and/or export of the same to Uganda
• Training of health professionals on optimum management of diarrhoea (this will improve ORT, lessen the unwarranted dependence on antibiotics, and increase the use of zinc).

The scaling up of zinc will not only benefit children of Uganda but will also impact on the entire East Africa because many doctors and nurses from the region receive their training in Uganda. Quality of care lags pretty behind even in tertiary care hospitals. In the rural communities, small repositories exist for seeking care for a child’s illness. It is imperative that inexpensive, better formulations of zinc (for example, dispersible tablets of zinc acetate) be introduced into both the formal and non-formal (shops) arms of the health care system.

Besides zinc, another important aspect of malnutrition and diarrhoea is the treatment of diarrhoea itself. Cases of cholera are treated outside the hospital in tents. Case management, including assessment of dehydration and knowledge about appropriate antibiotics and micronutrients is sub-optimal. 

A2Z, with support from Gates Foundation, initiated a ‘twinning exercise’ between different countries during the Micronutrient Forum meeting in April 2007. Bangladesh, in view of its vast experience in zinc scale up, was assigned to be the ‘mentor’ for Uganda in its efforts on scaling up zinc. 

The training workshop in Uganda: Following up on the assignment MNI conducted the training workshop for capacity enhancement of public healthcare staffs on diarrhoeal case management. It also conducted a workshop on promotion and possible scaling up of zinc nutrition in the management of diarrhoea. The 2-week long program which trained over 100 national trainers was highly appreciated by the MOH, Uganda. It was a ground breaking MNI success in the area of international capacity building. MNI activity influenced a string of happenings in the policy and programme environment.

• MNI technical team reviewed and facilitated pre-testing and printing of national guideline for CDD (Control of Diarrhoeal Disease) for the Village Health Team.
• Ugandan task group on zinc gathered precious insights from ICDDRB’s experience. Now with the financial aid of UNICEF it is set to procure zinc, which will be integrated in diarrhoea management.
• MNI engagement with MOH has created the impetus for leverage of funds. The Government of Uganda has commissioned a 4-fold rise of the CDD budget for the fiscal year 2008-09.