RBM Case Management Working Group Meeting, Geneva 8-9 th July 2009 1 |1 | Dr Wilson Were CAH/CIS...

RBM Case Management Working Group Meeting, Geneva 8-9RBM Case Management Working Group Meeting, Geneva 8-9thth July 2009 July 20091 |

Dr Wilson WereDr Wilson WereCAH/CISCAH/CIS

Community Case Community Case Management of MalariaManagement of Malaria

Community Case Community Case Management of MalariaManagement of Malaria

Child Adolescent Health and Development

RBM Case Management Working Group Meeting, Geneva, 8-9th July


Outline of PresentationOutline of PresentationOutline of PresentationOutline of Presentation

1. Overview of malaria control and access to treatment

2. Home management of malaria strategy

3. What it takes to implement HMM

4. Evidence for community based malaria case management


The Global Burden of Malaria

MOST DEATHS OCCUR AT HOME; WHAT CAN WE DO AT HOME TO STOP THE SCOURGE?

GLOBALLY 300 MILLION MALARIA CASES A YEAR

1 MILLION DEATHS, 90% IN CHILDREN IN

AFRICA


Global Status of ACT ImplementationGlobal Status of ACT Implementation

Countries which need ACT policy

Countries which adopted ACT

Countries Deploying ACTs

Countries Deploying ACTs at CommunityUpdate: Update:

June 2008June 2008


ACT Scale up 2001-2009ACT Scale up 2001-2009ACT Scale up 2001-2009ACT Scale up 2001-2009

0.5 0.6 2.1 5

31.3

82.7

97

130

160

0

20

40

60

80

100

120

140

160

180

2001 2002 2003 2004 2005 2006 2007 2008 2009

0

10

20

30

40

50

60

70

80

90

ACT procured No countries: ACT 1st line No countries deploying

Mill

ion

s o

f A

CT

tre

atm

ent

cou

rses

Cu

mu

lati

ve n

um

ber

of

cou

ntr

ies

Forecast6-24 months from adoption to implementation6-24 months from adoption to implementation


1) Challenges of Access to 1) Challenges of Access to Effective TreatmentEffective Treatment

1) Challenges of Access to 1) Challenges of Access to Effective TreatmentEffective Treatment

1. Most malaria treatments:- > 30 -70% occur outside the public health facilities

are self-medications, in sub-optimal dosage and quality

are out-of-pocket expenses in unregulated informal private sector

cost poor people a high proportion of family income

2. 50 -70% childhood deaths occur without contact with public health services

3. 90% deaths are children dying within 48 hrs of onset of illness

How to do we achieve global RBM and MDG targets for access to effective treatment within 24 hrsHow to do we achieve global RBM and MDG targets for access to effective treatment within 24 hrs..


2) Challenges of Access to Effective Rx:2) Challenges of Access to Effective Rx: Reaching Malaria Targets & GoalsReaching Malaria Targets & Goals

2) Challenges of Access to Effective Rx:2) Challenges of Access to Effective Rx: Reaching Malaria Targets & GoalsReaching Malaria Targets & Goals

☛ Roll Back Malaria Partnership • The aim (of Roll Back Malaria) will be to halve malaria-associated mortality by

2010 and again by 2015

☛ Millennium Development Goals • MDG 6: Target 8: Have halted by 2015 and begun to reverse the incidence of

malaria and other major diseases• MDGs 1, 4 and 5 malaria-related.

☛ World Health Assembly 2005• Ensure a reduction in the burden of malaria of at least 50% by 2010 and 75%

by 2015.


What is Home Management What is Home Management of Malaria? (HMM)of Malaria? (HMM)

What is Home Management What is Home Management of Malaria? (HMM)of Malaria? (HMM)

Is a strategy to enhance access to appropriate and effective malaria treatment in the community or home through early recognition of, and prompt and appropriate response/treatment to malarial illness".

Note: Note:

HMM should be designed as an integral part of the overall malaria case HMM should be designed as an integral part of the overall malaria case management strategy.management strategy.

Photos: TDR HMM research team


HMM Strategic ComponentsHMM Strategic ComponentsHMM Strategic ComponentsHMM Strategic Components

1. An effective communication strategy for behaviour change to enable

individuals/caretakers recognize malaria illness early and take an

appropriate action.

2. Equipping the community service providers with the necessary skills and

knowledge to manage and respond to malarial illness.

3. Ensuring availability and access to pre-packed antimalarial medicines

in the community as close to the home as possible.

4. A good mechanism for supervision and monitoring of the community

activities.


What is in the Package for HMM?...What is in the Package for HMM?...What is in the Package for HMM?...What is in the Package for HMM?...

Trained community providers (CHWs, Medicine

Sellers or Retailers) provided with:

– ACTs for treatment of uncomplicated malaria.

– rectal artemisinin suppositories for pre-referral treatment

of severe malaria.

– rapid diagnostic tests where applicable.

– information, education and communication materials.

– simple patient registers and reporting forms.

– medicine storage boxes


0

20

40

60

mor

talit

y/10

00

Intervention No intervention

All-cause mortality, children under-five, by intervention and no intervention, Ethiopia

0

5

10

15

perc

enta

ge

pre-pack not pre-packs

Proportion of children progressing to severe malaria, treated with pre-packs and not with pre-packs, Burkina Faso

Under-five overall mortality Under-five overall mortality reduced by 40% (Kidane, 2000)reduced by 40% (Kidane, 2000)

What is the Evidence for Community What is the Evidence for Community Based Management of Malaria?Based Management of Malaria?

Reduction in severe disease by 25-Reduction in severe disease by 25-50% (Pagnoni et al 1997;Sirima et 50% (Pagnoni et al 1997;Sirima et al., 2003)al., 2003)

1.1. Studies have shown good outcomes and Studies have shown good outcomes and impactimpact


Feasibility and Acceptability of Feasibility and Acceptability of Using ACTs: Ghana Experience…Using ACTs: Ghana Experience…

Feasibility and Acceptability of Feasibility and Acceptability of Using ACTs: Ghana Experience…Using ACTs: Ghana Experience…

78.8

8.75.8 4.8

1.90

10

20

30

40

50

60

70

80

Proportion of givers with children with fever who opted for the CDD-Rural

57.3

28

14.6

0

10

20

30

40

50

60

Same day Next day More than 2 days

P rompt treatment-Fever onset and seeking care- rural

2 .Prompt care seeking for children with fever1 .Community acceptability of CDDs

Source TDR/IR: Garshong, B et al 2007, Feasibility and acceptability of using ACTs for HMM in Ghana .


Tigray Community ACT Project: Tigray Community ACT Project: Quarterly Health Centre & Hospital Inpatient CasesQuarterly Health Centre & Hospital Inpatient Cases

Tigray Community ACT Project: Tigray Community ACT Project: Quarterly Health Centre & Hospital Inpatient CasesQuarterly Health Centre & Hospital Inpatient Cases

0

500

1000

1500

2000

2500

3000

Control Intervention

0

10

20

30

40

50

60

70

80

90

100

Total Inpatient Mal. Inpatient % Mal. Inpatient

ImpactImpact

Report of ACT Deployment at community level: Tigray Regional Health Bureau, Ethiopia, May 2008


Evidence on Programme Level or Large Scale Implementation


ACT Implementation Status in AfricaACT Implementation Status in AfricaACT Implementation Status in AfricaACT Implementation Status in Africa

WHO/GMP, June 2008WHO/GMP, June 2008

Countries which need ACT policy

Countries which adopted ACT policy

Countries Deploying ACTs

Countries with ACTs at Community level

Countries without malaria


HMM country experience: CambodiaHMM country experience: CambodiaHMM country experience: CambodiaHMM country experience: Cambodia

0

10

20

30

40

50

60

70

80

90

100

CommunityEffectivenes

Confirmed Dx

%

Non-Intervention

Out-reach Areas

Village Malaria Workers

Yeung S et al, Access to ACTs in remote Cambodia,7:96 Malaria Journal 2008Yeung S et al, Access to ACTs in remote Cambodia,7:96 Malaria Journal 2008


HMM country experience: RwandaHMM country experience: RwandaHMM country experience: RwandaHMM country experience: Rwanda

USAID, BASICS & MSH external evaluation report of HMM, PNLP Rwanda, 2007


Rwanda Launches ACTs for HMM and use in private sector

Increasing AccessIncreasing Access

AMD 25th April 2007


What Partners need to Scale Up What Partners need to Scale Up HMM implementationHMM implementation

What Partners need to Scale Up What Partners need to Scale Up HMM implementationHMM implementation

Setting up community systems- provider selection, training material development and training

Setting up community referral systems and quality of care at health facilities.

Record keeping and reporting tools.

Quality assurance, supervision and monitoring community activities.

Motivation and retention of the community based providers.

Photos: TDR HMM research team


WHO PublicationsWHO Publications

http://www.who.int/malaria/homemanagementtechnicalreports.html

RBM Case Management Working Group Meeting, Geneva 8-9 th July 2009 1 |1 | Dr Wilson Were CAH/CIS...

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