Home Based Management of Fever in IDP camps in northern Uganda

Situation:

Malaria is the number one cause of child morbidity and mortality in sub-Saharan Africa, therefore prompt and effective treatment is considered the most important control strategy. Home Based Management of Fever is the process by which clinical cases of malaria in the under fives can be recognised and treated at home by their care givers. As children can very rapidly develop severe malaria, which carries a high mortality risk, prompt effective treatment is paramount.

Numerous studies have shown that many cases of malaria are not brought to the formal health sector for treatment: antimalarial drugs are widely available in the marketplace, and children are often treated at home with over-the-counter medication bought from shops. This is thought to be so common that it is recognised as an important means of malaria control if it can be done well, and HBMF brings the point of care even closer to the patient.

Response:

The Malaria Consortium works in partnership with the Ministry of Health in Uganda to implement Home Based Management of Fever (HBMF) and make affordable, appropriate treatment available to children at home within 24 hours of a clinical diagnosis. Under this strategy, trained community workers distribute pre-packaged drugs (Homapak®, chloroquine and sulfadoxine-pyrimethamine (SP)), to caregivers of febrile children, to advise on how to continue treatment at home and to refer those who have danger signs, or who fail to improve, to a qualified health worker. (NOTE: chloroquine plus SP was first-line treatment when the programme began, but in response to rising drug resistance, the Ministry of Health is changing to artemisinin-based combination therapy (ACT), initially in health facilities and imminently in the HBMF programme).

The Malaria Consortium introduced the HBMF system in the conflict-affected districts of northern Uganda in Internally Displaced Persons' (IDP) camps. Capacity was built within the district health teams and local partners to ensure sustainability of the intervention.

A household survey was carried out in one of the implementation districts and found the following: over 1,100 volunteer community medicine distributors (CMDs) were trained and 170,000 fevers among under-fives treated within the first 12 months. In total, over 550,000 fevers have been treated. Access to prompt case management has increased markedly with the average percentage of children treated within 24 hours rising to 62%. The intervention was able to demonstrate a significant impact on anaemia with severe anaemia being reduced by 61% among children aged 6-24 months.

A Monitoring and Evaluation (M&E) system was established which included patient registers to track fevers treated and adverse events as well as a rigorous pre- and post-intervention survey to measure impact on childhood anaemia. We are currently undertaking a large-scale validation of the implementation model for using ACTs (as well as use of Rapid Diagnostic Tests) at community level in Uganda. This delivery model is being integrated within the broader home based care system funded by UNICEF.

Cost of delivery: In the northern Uganda setting the cost of delivering antimalarials to children living in the IDP camps is 48 cents per fever treated.

Packaging and Inserts: The use of blister packs to package antimalarials was considered better than loose tablets, as it kept the treatment clean and dry. The instructions are rarely useful, due to the high illiteracy rate so adherence with treatment is heavily dependent on the medicine distributors.

Access to prompt appropriate treatment: The odds of children receiving appropriate, prompt treatment were 5 times greater in the study area than in the non-intervention area.

CMDs play an important role in the control of malaria in IDP camps, some of them providing presumptive malaria treatment for febrile illness to more than 60 children per month. Many are highly motivated despite limited or no support or incentives.

Points to note:

This community health worker system, on which this intervention relies heavily, needs:
- Adequate resources to ensure regular supervision by health workers
- A defined package (e.g. recording materials, medicine storage container), to enable them to carry out their work
- Strong involvement with the health structure
There is a need to replace the current antimalarial combination (chloroquine and sulfadoxine-pyrimethamine) with a more efficacious treatment, and this has been initiated
Good communications and local leader support is central to the sustained success of the strategy

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Photo: Malaria Consortium