2. 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

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

4. 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

5. 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

6. 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 –E ducating 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

7. 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

8. 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

9. 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

10. 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

11. Status of implementation-cont’d

12. 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

13. 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

14. 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

15. 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

16. Unit cost by activity

17. 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

18. 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

19. 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)

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

21. 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

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

23. 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.

24. 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.

25. I Thank you for listening