Strategy without deployment: converting Uganda’s antimalarial resistance plan into practice before treatment failure becomes routine

Abstract Partial resistance to artemisinins is no longer a southeast Asian problem. Uganda now reports validated and candidate pfkelch13 markers at high allele frequencies across most surveilled districts, The resistance signal now extends to children hospitalised with complicated malaria, where the pfkelch13 A675V variation has been associated with slower parasite clearance but not with 28-day recrudescence, and where a larger prospective cohort has since found no association between variant carriage and worse clinical outcomes. Uganda has responded. The National Malaria Elimination Division began planning a resistance response in 2023, the Ministry of Health issued a national strategy to respond to antimalarial drug resistance in 2025, and a Uganda-calibrated modelling analysis has now quantified the expected benefit of the main deployment options. The remaining gap is therefore not one of intent but of execution, and of evidence. No validated molecular marker exists for lumefantrine, so molecular surveillance cannot yet time or target partner-drug decisions, which continue to rest on therapeutic efficacy studies and modelling. This Perspective argues that Uganda's task in the second half of this decade is to convert an existing plan into deployment. It sets out four priorities: reducing public-sector reliance on artemether-lumefantrine along the lines the modelling supports, extending therapeutic efficacy monitoring to severe malaria, closing the partner-drug marker gap as an explicit research priority, and strengthening antimalarial quality assurance. Acting before treatment failure becomes routine offers the best chance of preserving the antimalarials on which Ugandan children depend.