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

1. 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

2. Presentation layout • Introduction • HBM what, why • Objectives • Implementation steps and package • Status of implementation & Achievements • Enabling factors • Scaling-up plan • Challenges • Future Plans & Conclusion

3. 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

4. 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

5. 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

6. 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

7. 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

8. Implementation: package 1. Communication strategy for behaviour change 2. Pre-packaged C/Q &SP unit packs (HOMAPAK) 3.Guidelines fortraining mothers/caretakers, drug distributors & community mobilisation 4. Tools for recording and monitoring

9. Steps Output No.of districts implemented Sensitization and planning with districts District plans 21 Training of district trainers District & subcounty trainers 10 Sensitization of sub counties Community mobilizers 10 Sensitization of communities & selection of drug distributors Selection of distributors/mothers 10 Training of drug distributors/mothers Trained distributors 10 Status of implementation

10. Status of implementation-cont’d

11. 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

12. 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

13. 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

14. 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

15. Unit cost by activity

16. 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

17. 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

18. 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)

19. Implementation of Home-Based Management of Fever Strategy in Uganda Key: HBM implementing districts SHSSPP districts (ADB) HBM scaling-up districts

20. 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

21. Challenges • Private sector involvement for additional drug supplies • “Doctors” out of distributors • How to keep volunteers interested

22. 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.

23. 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.

24. I Thank you for listening