Home and community management of malaria – key to sustainable targets

community-med-distrib-uganda-sm.jpgBBC is featuring community medicine distributors in Uganda as part of its series on ‘Survival TV’. While the video starts with how things were in a Ugandan community with a funeral of a child who died from malaria, the work of two community medicine distributors in combating malaria with readily available packs of Coartem® (arthmether-lumafantrin) and long lasting insecticide treated nets (LLINs) ultimately provides a positive outcome for Ugandan children.

Home management of malaria (HMM) is not new to Uganda. Kolaczinski and colleagues reported, “In 2002, home-based management of fever (HBMF) was introduced in Uganda, to improve access to prompt, effective antimalarial treatment of all fevers in children under 5 years. Implementation is through community drug distributors (CDDs) who distribute pre-packaged chloroquine plus sulfadoxine-pyrimethamine (HOMAPAK®) free of charge to caretakers of febrile children.” Caregivers for children were impressed by the safety of the blister packs, and having been guided be the CDDs 95% of them had administered the correct dose of medicine to their children.

The medicines have changed to arthmether-lumafantrin now, but a recent 3-country assessment “provides encouraging data on parasitological outcomes of children treated with ACT in the context of HMM and adds to the evidence base for HMM as a public health strategy as well as for scaling up implementation of HMM with ACTs.” On average correct adherence was 94% across Uganda, Ghana and Nigeria.

The benefits HMM are not just to the individual child and family, but also to the health system. Sievers and colleagues found in Rwanda that “both admissions for malaria and laboratory markers of clinical disease among children may be rapidly reduced following community-based malaria control efforts.” They also cautioned that as malaria cases and hospital admissions became less frequent, “More accurate diagnosis and management of febrile illnesses is critically needed both now and as fever aetiologies change with further reductions in malaria.”

Another effect of properly organized HMM is reflected in the title of a new article appearing in Malaria Journal: “Implementation of home-based management of malaria in children reduces the work load for peripheral health facilities in a rural district of Burkina Faso.” Not only were fewer children with malaria seen at health facilities in the intervention communities, but in fact more children in those communities were actually treated for malaria in those communities.  HMM clearly improved access to correct malaria treatment.

cdi-study-malaria-sm.jpgThis access issue was demonstrated in a study by the Tropical Disease Research (TDR)project of UNDP, World Bank, WHO and UNICEF. In districts using CDDs for HMM more children were reached. In fact excepting Cameroon where there were policy and logistical challenges to community drug distribution, reaching the RBM targets was seen as feasible through HMM compared to where malaria treatment was made available only through the normal health care system.

The TDR project built on the successful experience spanning over a decade of ivermectin distribution to control onchocerciasis. When community directed distribution started, health workers worried that communities were not capable to taking charge on medicines. Later they learned that not only could communities deliver ivermectin safely and accurately, but that they could maintain good annual treatment coverage. Finally the health workers learned that community directed distribution helped the health system reach ‘people beyond the end of the road’ who otherwise would not have benefitted from services.

HMM empowers the community and enhances the ability of the health system to reach those in need. HMM should be a central strategy in any malaria control program.

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