The private sector: A critical factor in Uganda’s response to antimalarial drug resistance

Malaria treatment in Uganda is becoming less reliable, and the consequences are already emerging. 

A 2023 study found that in 11 of 16 districts surveyed in Uganda, one in five malaria infections carried markers linked to drug resistance. At the same time, the efficacy of the drug artemether–lumefantrine, the first-line treatment for uncomplicated malaria, has fallen below the 90 percent cure rate recommended by the World Health Organization (WHO) in regions such as Arua and Busia. 

These trends point to a growing challenge that demands attention. Uganda’s draft Strategy to Respond to Antimalarial Drug Resistance — a coordinated, multi-pillar response — recognises the complex interplay of factors driving antimalarial drug resistance:  

• Treatment and use: overuse of artemether-lumefantrine, use of artemisinin monotherapies, incorrect dosing, and poor adherence to treatment guidelines in public and private settings 
• Health system and market environment: weak regulation, limited access to quality diagnostics, substandard medicines and inadequate reporting, particularly in the private sector 
• Patient behaviours: delayed care-seeking, self-medication and poor adherence to full treatment courses 
• Transmission and biology: ongoing transmission and emerging genetic mutations that are accelerating resistance 
• Funding constraints: under-investment in surveillance, quality assurance and supervision. 

The response to antimalarial resistance is gaining momentum. Countries and partners are investing in stronger surveillance, better diagnostics, improved treatment practices, limiting the spread of resistant parasites through integrated vector control and chemoprevention, increased research and innovation, and stronger governance. 

Yet they will only succeed if they reflect how people actually access malaria care. That means paying much closer attention to the private sector, a major source of diagnosis and treatment in many endemic settings, but also a space where weak regulation, poor-quality medicines, inappropriate dispensing and gaps in reporting can accelerate the spread of resistance. 

The blind spot 

Currently, almost 60 percent of caregivers of children seek care from the private sector. In these drug shops, pharmacies and private clinics, malaria care is shaped by economics as much as by clinical guidance: affordability, patient demand, time pressure and inconsistent access to quality diagnostics. Patients purchase partial doses when they cannot afford full treatment. Providers adapt prescriptions to what clients can pay. Diagnostics are not always reliable, and treatment decisions are sometimes influenced by expectations rather than guidelines. 

Uganda’s national strategy identifies these private sector inefficiencies as a significant driver of drug resistance. Yet in practice, attention and investment in the private sector have not kept pace with the role it plays in delivering malaria treatment.  

Resistance as a system and market failure 

These dynamics point to a deeper problem. Antimalarial drug resistance is still too often framed as a knowledge problem, solvable through training. However, evidence from Uganda shows that providers understand the guidelines; the constraint is the system within which providers operate. 

Inadequate supervision, fragmented regulation, limited reporting, poor-quality diagnostics and misaligned financial incentives combine to make inappropriate use of antimalarials the default. These dynamics are especially acute in the private sector but are by no means exclusive to it. Similar adherence failures occur in public facilities, and the consequences of drug stockouts in the public sector push patients into unregulated private markets. 

What actually changes outcomes 

Experience from Malaria Consortium’s work in high-burden districts shows that behaviour shifts when systems shift. When private providers are routinely supervised, equipped with quality diagnostics, integrated into reporting systems and aligned with national standards, adherence improves.  

To address the structural drivers of antimalarial drug resistance in the private sector, we are supporting a model that aligns supervision, commodities, data systems and incentives at the point of care within routine district systems. This approach moves beyond training to address the system and market conditions that shape provider behaviour.  

The approach is already being implemented in Uganda. We have supervised 220 private health service providers in eight districts, and supported the mapping and coordination of key partners, strengthening oversight and alignment with national guidelines. 

Why this matters for malaria financing 

Without addressing antimalarial drug resistance in the private sector, existing investments in malaria prevention efforts are at risk. 

Funding for nets, vaccines and case management assumes that effective treatment is delivered at the point of care. If that care is compromised — as it often is in unregulated private markets — the return on those investments diminishes. Therefore, protecting past and future investments requires shifting focus to where treatment actually happens. 

The strategic shift  

Containing antimalarial drug resistance will require moving from engagement to stewardship of the private sector: 

• Embedding routine supervision and regulatory oversight
• Ensuring access to quality-assured diagnostics and medicines 
• Integrating private providers into national surveillance systems 
• Addressing market drivers, including affordability and incentives. 

The path forward 

Uganda’s draft national strategy is clear. The response must be comprehensive: from strengthening surveillance and diagnostic quality, to sustaining vector control, accelerating vaccine rollout, improving governance and mobilising resources across all pillars. The private sector, while not the only consideration in this national effort, is a critical one that has been under-scrutinised relative to its importance. 

Malaria Consortium offers a proven pathway: an operational model that integrates district health systems with private providers, aligns incentives, strengthens supervision and embeds data into national systems. If the first point-of-contact for malaria treatment happens through the private sector for over half of households, then the future of malaria control will partly be decided there. Antimalarial drug resistance will be contained, or accelerated, through everyday treatment decisions in private outlets, as well as through policy. 

Drug-resistant malaria is a complex, multi-driver threat. It will not be resolved by acting on any single lever. But the private sector, where most Ugandans seek their first malaria treatment, cannot remain a blind spot in the national response. Addressing it must be a priority, alongside the broader systemic investments.