Home Management of Malaria HMM Strategy

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Home Management of Malaria (HMM) Strategy
5th INTERCOUNTRY MEETING OF NATIONAL MALARIA
PROGRAMME MANAGERS

• 29th 31st MAY ?2005
• CAIRO, EGYPT.

Dr. Wilson Were, Medical officer Access to Prompt
and Effective Treatment Malaria Policy and
Strategy Team Roll Back Malaria Department WHO
Headquarters
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THE GLOBAL BURDEN OF MALARIA
GLOBALLY OVER 300 MILLION MALARIA CASES A YEAR
1 MILLION DEATHS, 80 IN CHILDREN IN AFRICA
MOST OF THESE CHILDREN DIE AT HOME WHAT CAN WE
DO AT HOME TO STOP THIS
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Levels of interventions
Resolved
Cured
Cured
Non- Infected
Infected
Disease
Severe
Death
HOME
Community
Peripheral H.S.
Hospital
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Effective interventions are available
Resolved
Cured
Cured
Non- Infected
Infected
Disease
Severe
Death

• Integrated Vector control
• Intermittent Preventive
  Therapy in pregnancy
• Early Epidemic Detection and Prevention
• Travellers Chemoprophylaxis

• Early Diagnosis and prompt Appropriate effective
  Treatment
• Referral and Hospital-based case management
  severe cases

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Current Situation of Access to Treatment in
Endemic Countries (1)

• 50 -70 childhood deaths occur without contact
  with general health services
• Some communities rely heavily on self-treatment
• in Africa, gt 70 of fever episodes in rural areas
  gt 50 in urban areas are self-treated.
• most of this treatments are inappropriate, i.e.
  only lt 15 malaria patients are treated
  correctly.

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Current Situation of Access to treatment in
Endemic Countries (2)

• Why these common treatment practices?
• Less than 50 of malaria treatments occur in the
  public sector.
• Reasons
• long distances to facilities
• services unavailable at times of need
• drug stock-outs in health facilities
• provider inappropriate behaviour
• user fees in poor populations
• Presence of poor quality counterfeit drug trade
  in the informal private sector.
• Poor compliance sub-optimal doses due to lack
  of information keeping drugs for the next
  episode.

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Antimalarials are used Inappropriately
Inadequate dosage taken by patient
Kenya
Inadequate dosage sold by shopkeeper (Kirigia et
al, 1998)
Caregiver/patient did not know the correct dosage
(Makubalo, 1991)
Zambia
Nigeria
Caretaker gave inadequate dose (Eizie et al 1990)
Caretaker gave Inadequate dose (Deming et al.,
1989)
Togo
of persons interviewed
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Quality of Antimalarial Drugs on the Market
(Content Dissolution)
Percent Failure ()
WHO/EDM survey in Africa, May 2003
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Why Early and Effective Treatment
Majority of children who die from malaria
do so within 48 hours of onset of illness.
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There are public health gains

• Studies have shown that the strategy-
• reduces by 25-50 progression to severe disease
  (Pagnoni et al 1997Sirima et al.,
  2003).
• reduces under-five overall mortality by 40
  (Kidane et al, 2000).
• Unit-dose pre-packaging can improve adherence to
  treatment (Ansah et al 2001).
• Training community drug providers (CHWs, village
  volunteers, and schoolteachers) is effective and
  feasible.

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Evidence for HMM public health gains

• Studies have shown good impact

Under-five overall mortality reduced by 40
(Kidane, 2000)
Progression to severe disease reduced by 25-50
(Pagnoni et al 1997Sirima et al., 2003)
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Definition of HMM

• "Malaria case management occurring outside the
  health facility clinical setting within the home
  or community especially in children under 5 years
  of age".

HMM should be designed as an integral part of the
overall RBM strategy on case management
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Overall Goal and Objectives

• To achieve early recognition and prompt
  appropriate treatment of, and other responses to
  malarial illness especially in children less than
  5 years of age in the home or community"

Objectives

• Enabling caretakers to recognize malaria illness
  early and take appropriate action
• Ensuring that care providers have adequate
  knowledge and skills to respond malaria
• Creating an enabling environment to implement the
  strategy

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Strategic components

• An effective communication strategy for behaviour
  change to enable individuals/caretakers recognize
  malaria illness early and take an appropriate
  action.
• Equipping the community based service providers
  with the necessary skills and knowledge to manage
  malarial illness.
• Ensuring availability and access to effective
  quality pre-packed antimalarial medicines in the
  community as close to the home as possible.
• A good mechanism for supervision and monitoring
  of the community activities.

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Who are the possible community service providers

• Community health workers
• Community resource persons e.g. teachers, opinion
  leaders, community leaders, C-IMCI trained
  persons
• Community health agents
• Medicine vendors

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Examples of communication strategies

• Media TV spots in Ghana improved proper drug use
  ("HeHaHo" programme Ghana)

• Use print media and IEC materials improved
  communication to communities

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Packaging and training of service providers

• Unit-dose pre-packaging improves compliance (Ansh
  et al 2001).

• Training shopkeepers or drug vendors is feasible
  may improve dispensing practices (Marsh et al
  1999).

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Training of community service providers

• Training community health workers at village
  level is feasible (Uganda experience, MOH,2003)

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Enabling Environment

• Policies that allow strategy implementation
• Ownership of the strategy by all stakeholders
• Availability of implementation resources
• Conducive environment for service providers
• A clear linkage with the nearest health
  facilities
• Integration within the overall district and local
  health plans

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Outline of implementation steps

• Preliminary steps- a situation analysis Goals
• Establish a core working group partnerships
• Mobilize resources through advocacy
• Address drug policy and regulation issues
• Address medicine management issues-
  pre-packaging, procurement and supply systems
• Develop and implement country specific
  communication strategy
• Develop training approach identify providers,
  content, materials and tools
• Develop implementation steps at district and
  community levels

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Monitoring and Evaluation

• Use RBM and MDGs indicators
• Specific program indicators
• Early implementation process
• Knowledge and health seeking
• Medicine supply and management
• Communication strategy
• Outcome indicators
• Impact indicators

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Available WHO Documents on Community involvement
in malaria management
In Press Implementation Guidelines Under
Preparation Community health workers training
manual
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Conclusions

• HMM is recognized as a key strategy for improving
  access to treatment in Rolling Back Malaria
• Substantial evidence of benefit - treatment
  near-the-home reduces childhood morbidity and
  mortality
• Decades of experience in countries of community
  involvement in malaria disease management
• Implementation poses significant challenges to
  health systems, and all stakeholders
• There are still gaps in the strategy requiring
  further operational research and proper
  documentation

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Thank YOU
There is hope for winning the battle through HMM