RBM/IMCI JOINT TASK FORCES MEETING, SEPT 24-26/2002 HARARE

ZIMBABWE.

SCALING-UP HOME BASED MANAGEMENT OF FEVERS (HBM)

PRESENTED BY Dr. CHRISTOPHER KIGONGO

SMO/MCP

Presentation layout• Introduction

– HBM what, why

• Objectives• Implementation steps and package• Status of implementation & Achievements• Enabling factors• Scaling-up plan• Challenges• Future Plans & Conclusion

Introduction:What is HBM?• A strategy through which pre-packaged Chloroquine

and SP are provided at home and community level for treatment of fevers among children under five years

• It entails:– training of mothers to recognize disease and take action

eg treatment at home – training drug distributors to treat fever cases, advise

mothers/caretakers, and keep record of services provided– supply of pre-packed drugs to the drug distributors

treatment from trained health workers

Introduction:Why HBM?• Access to proper malaria treatment is low

– Only 49% of the population live within 5 Km of a formal health care facility

– Only 42.7% of parishes in the country have HC II

• Home management of fever is already a problematic reality – Up to 83% of fever cases are managed outside formal

facilities– 79% of the above is “self medication “ using western type

of medicine; drugs are given incorrect, in incomplete doses and often dangerous combinations

Introduction:Why HBM? • There is evidence that home management reduces

morbidity& mortality & is acceptable

– A pilot project in 3 districts of Uganda with pre-packed Chloroquine (MUSUJAQUINE) showed high compliance to treatment

– Educating mothers and providing them with Chloroquine, for home treatment of fever reduced mortality in children in Ethiopia

– Provision of pre-packed drugs reduced prevalence of severe forms of malaria in Burkina Faso

HBM: Objectives• To increase access to prompt and appropriate

treatment of fever/malaria among children below five years

• To improve on recognition of children with severe illness and ensure prompt referral to formal providers

• To support preventive Malaria control strategies e.g. IPT & ITNs

Implementation: steps

A national core team was formed to develop guidelines, packages and tools and build district capacity. Six key steps were followed:

1. District sensitization and planning

2. Training district trainers

3. Sensitization of sub counties

4. Community & selection of drug distributors

5. Training of drug distributors/mothers

6. Distribution of drugs at community level

Implementation: package

1. Communication strategy for behaviour change

2. Pre-packaged C/Q &SP unit packs (HOMAPAK)

3. Guidelines for training mothers/caretakers, drug distributors & community mobilisation

4. Tools for recording and monitoring

Status of implementation

10Trained distributorsTraining of drug distributors/mothers

10Selection of distributors/mothers

Sensitization of communities & selection of drug distributors

10Community mobilizersSensitization of sub counties

10District & subcounty trainersTraining of district trainers

21District plansSensitization and planning with districts

No.of districts implementedOutputSteps

Status of implementation-cont’d

District Steps1 2 3 4 5 6

Adjumani Nakasongola Rukungiri **Kumi Masindi ** **Kamuli ** ** **Kyenjojo ** **Kanungu Kabalore ** **Kiboga ** **

means activity has been completed; ** means that the activity is on going;

Achievements• National steering committee established

• POA developed and agreed with Partners

• HBM launched by His Excellence the President of Uganda

• All DDHS sensitized about the HBM

• HBM activities initiated in all 21 first phase districts

Achievements-cont’d• Communication strategy has been developed • Guidelines & tools for training district trainers,

selection and training of drug distributors,record keeping, supervision & monitoring

• Procured 4 million unit doses of HOMAPAK

• Trained 490 district trainers in 10 districts• Trained 10,000 drug distributors in 5,000 villages

(number of villages 39,690 whole country, 19,330 in 21 districts)

• Baseline survey has been done and data is being analyzed

Reports from implementing districts

• OPD attendances have reduced

• In patient admissions have dropped as well

• The above have to be verified and effects on mortality assessed

Enabling factors• Highest political commitment• Community’s recognition of malaria as a

problem• Pro-active program integration & sector wide

approach• Partner coordination through the ICCM• Supportive NGOs, Civic & Cultural groups in

addition to the private sector

Unit cost by activityActivity Cost in US dollars

District sens. & planning $ 680, 30 people, 2 days

District TOT $1120, 30 people, 2 days

Sub county sensitization $105, 20 people, 1 day

Village selection of DDs $ 6.2, per village

S/county training of DDs $350, 35 people, 2 days

Drug distribution No direct cost

Cost of treating a child for 1 year (6 episodes) $ 0.96

Enabling factors-cont’d• Strong Malaria-IMCI collaboration• Strong inter-partner collaboration e.g.

UNICEF/WHO, BASICS/WHO, USAID/DFID, • Well embracing health sector policy & Strategic

plan• Available experience from the TDR study home

based management• Presence of a large number of personnel trained

in IMCI

Enabling factors-cont’d

• Decentralization of political/administrative system with local councils at village level

• Presence of NGOs within the communities which already work with mother on nutrition

• Presence of PDCs & CORPs in many communities, not being used.

• High utilization of the informal sector by community members.

• The wide network of FM radios (National wide coverage)• Strong women movement & their empowerment

Scaling up HBM

• Improving the practice of Home management of fever started in 1999 in 3 districts with support from TDR

• Scaling up commenced 2002 and is done in a phased manner

- First phase 21 districts (already started)

- Second phase 15 districts (starts February 2003)

African Development Bank 11 districts

Standard Chartered Bank 4 districts

- Third phase 20 districts (starts within one year)

Implementation of Home-Based Management of Fever Strategy in Uganda

HBM implementing districts

SHSSPP districts (ADB)

HBM scaling-up districts

Key:

Challenges • Emerging Chloroquine & Sulphadoxine-pyrimethamine

resistance • Low resource base at lower administrative levels• Sustenance of drug supply• Referral mechanisms in the health systems still weak• Negative health workers’ attitude & low motivation• Supervision of drug distributors- low number of health

workers• High political pressure to cover the entire country quickly

Challenges Private sector involvement for additional drug

supplies “Doctors” out of distributors How to keep volunteers interested

Future perspectives • Cover the whole country as soon as possible (in about 1

year)• Work with the private sector for the development of the

private arm of HOMAPAK. • Develop unit dose packs for older children and adults• Monitor drug resistance and adverse reactions• More operation research and measuring impact• ITNs promotion to be integrated into HBM• Subsidies on ITN to be introduced for under fives and

pregnant women in HBM areas.

CONCLUSION

• Scaling up the HBM is challenging but possible

• It requires adequate capacity strengthening at the different levels and good partner coordination.

• HBM has benefits visible to the community and should be encouraged every where children are suffering febrile illness.

I Thank you for listening