Mothers can cure malarial feveres, but research funding problems are slowing application.

SUMMARY: Training, communication and provision of antimalarials at the community level cut malaria mortality by 40% in trials in the late 1990s. In Uganda, the scheme has been extended to most major child health issues, using public and private partners, and stimulated the creation of a country-wide network of multi-purpose “community drug distributors”. So why isn’t it widespread? In the case of malaria, we await a major study on the community distribution of artemisinin combinations. But the principles the approach pioneered could be applied universally. >by Robert Walgate, Editor, RealHealthNews

How could the public and private sectors unite to help African mothers and carers save their children from dying of malaria, and provide a model for an engaging and complete health system? Potentially, by adopting and extending the scheme known now as Home Management of Malaria (HMM).

When trialled in 37 villages in rural Ethiopia in 1997, HMM reduced under-five mortality by 40%. In 32 villages in rural Burkina Faso in 1998-99, HMM reduced severe malaria in children by nearly a half.

So what is HMM? In the original trials in over 6000 children in Ethiopia, “mother coordinators” were trained to teach other local mothers to recognize symptoms of malaria in their children and to promptly give a complete course of chloroquine.

In Burkina, opinion leaders (mainly older mothers) were trained in the management of uncomplicated malaria, including the administration of dose-specific pre-packaged chloroquine – and the chloroquine was also sold through the local markets.

Even though they had to pay, mothers treated 56% of potentially malarious fevers with the drugs within a day of onset of illness, and reduced the progression of those fevers to severe malaria by 47%.

According to Jane-Frances Kengaya-Kayondo, the researcher who pioneered HMM at the Tropical Disease Research Programme (TDR), Geneva, “earlier research had shown that in most countries 80% of malaria episodes, particularly in children, are dealt with at home using available resources, whether traditional, herbal, or medical of some nature.”

“But this treatment is almost invariably inappropriate,” she said. “They start late, get the wrong treatment, and even when they get the right treatment they don’t comply with it.” And “in a Tanzanian study 90% of under-five kids died without even one contact,” she said. “So these two arguments really inspired TDR to find ways of increasing access to care, providing appropriate care, and ensuring compliance.”

A key question was “who can deliver nearer home?” Different countries tried different approaches, from community-based volunteers, who could be male in some studies, or mothers who could be trained and given basic skills of how to take a decision that this child needs on-the-spot treatment for malaria, or immediate referral. “So they developed training programmes to do that,” Kengaya-Kayondo said.

They next question was “what intervention?”

“When we started four or five years ago, chloroquine was still the drug of choice in many countries. So what we did was to package unit dose blister packs for kids, so they had a dose for under one year, and a dose for 1-6 years, with different colour codes so the community-based providers could easily learn, even if they were illiterate, that the red one was for the baby and the white one for the child. It was one tablet a day for three days. So they had these drugs in their hands all the time.”

“Then of course we had to study the system – how does it link with the nearest dispensary or health centre, because they can provide the support, the training, keep up the supply of drugs. So in some countries like Kenya and Uganda, where shopkeepers are the main outlets of drugs, we developed shopkeeper training programmes, to provide appropriate treatment and good information on how to use it. And we tested this.”

Thus HMM was adopted in Uganda, Kengaya-Kayondo’s home country, and has become the inspiration for a widening series of health activities, with the Ministry of Health eager to apply it to other health issues, as both a delivery and communications tool.

However the focus has been less on mothers (or more generally, carers), who remain a vast under-used resource, than on training private providers (“community drug distributors”, CDDs) in child and mother’s health, vitamin A distribution, growth monitoring, health promotion, diarrhoea management, and acute respiratory infection management.

So in another study, the Ugandan Malaria Partnership Project – led by the African Medical and Research Foundation, AMREF – has tested training CDDs to communicate on insecticide treated nets and intermittent preventive therapy (see references below).

According to AMREF Director Michael Smalley, after UMPP training, households using at least one bednet increased from 11% to 37% in one district, and from 1.4% to 14% in another.

Some 40% of the CDDs were dropping out of the programme after a year, said Smalley. But AMREF reduced this to 1-2% by offering self-respect – by connecting them with the primary health care system, and providing T-shirts labelled “Ministry of Health”, drug boxes and bikes to get around the community, he said.

The Kampala Pharmaceutical Manufacturer’s Association has also been a key HMM partner, preparing the original pre-packed antimalarials – chloroquine plus sulfadoxine-pyramethamine, called “HOMAPACK”. From the manufacturers’ perspective the Uganda scheme divides into two parts – the public sector, free provision of HOMAPACK, and a private sector scheme where the drugs are sold at “market price”. In Uganda “a good number of people go to the private vendors”, especially in the peri-urban areas, which are not well served by the public health system, says WHO’s Wilson Were.

In fact according to a 2002 government report “A recent literature review on malaria treatment revealed that in peripheral Kampala, ordinary shops and drug shops are the source of drugs for 80% of cases.” And even in rural Kabarole District in West Uganda, “51% of households obtain malaria drugs from shop vendors and other informal practitioners, and 20% from health centres.”

So Uganda has produced a “training and negotiating guide” along with monitoring guidelines for improving the child health care practices of private providers, creating a wide network of community drug distributors (CDDs).

HMM has shown that “all kinds of people can be engaged in providing treatment,” says Pagnoni. “In rural communities it’s mainly farmers and teachers, in urban areas chemical sellers and even shopkeepers like barbers and video-shop managers.”

A chemical seller in Ejisu-Juaben, Ghana, used to sell chloroquine syrup for childhood malaria – and made a small profit on the sale. According to Pagnoni he now distributes pre-packaged artemisinin combination therapies (ACTs), on which he makes no profit, but he expresses satisfaction with his task because the drugs are very effective.

In this research study the ACT price is being held low, but significant (0.11 USD for a child of 6-11 months, 0.22 USD for a child of 12-59 months). Since the drugs are provided free to the project, the money collected from sales is being saved until a decision is made on how it is to be used.

So why do local people participate in providing treatment for malaria? Probably because the drugs save lives – raising self-respect, the respect in the community for the ‘distributor’, and the status of his or her shop.

So where next? “More than 25 malaria-endemic countries in sub-Saharan Africa have incorporated HMM in their malaria control plans and in their applications to the Global Fund,” says Pagnoni.

However there’s a problem, he says – the malaria drug resistance that led to WHO’s recommendations for the use of artemisinin combinations therapies (ACTs), which were not the drugs originally tested. “We need to adapt the HMM strategy to the use of ACTs,” says Pagnoni. “We are working very hard in TDR, to raise the funding we need. We need research to provide data quickly on the feasibility, acceptability and effectiveness of HMM with artemisinin combinations.”

HMM provides an opportunity for public-private partnerships, says Pagnoni, “including itinerant vendors and shopkeepers in addition to organizations.” There are “interesting and innovative” partnerships ongoing in Nigeria and Kenya, he says.

The drugs provided by such systems should not be free, so users will value them, but equally the price should be controlled to an affordable level, Pagnoni believes.

“In the HOMAPACK programme in Uganda, the Ministry of Health has decided to make the drugs available at no cost to the family. It was a political decision coming from the highest level, that goes beyond technical considerations. My personal view based on experience, is that it is wise to charge a token amount of money for the drugs, in the range of what chloroquine used to cost or just a bit more.”

“We shouldn’t aim to recover the cost of the drugs. The drugs should be fully subsidized and all national and international efforts should be made to ensure thus. The funds generated from the token payments should be used locally, in the same community they came from, to motivate drug distributors, supervisors, district health teams and other actors involved in the programme.

This, for instance, has been shown to work in Burkina Faso, and is the recommendation coming out of the recently completed TDR study in Ghana,” says Pagnoni.

So how can HMM be applied more widely? Some fear that HMM works only “vertically”, for malaria alone, giving no benefit to the rest of the health system. But according to Franco Pagnoni of TDR, who continues work on HMM.

The increasing application of HMM methods to other health issues belies this. And “it’s by nature horizontal,” says Pagnoni, “as it’s implemented at the most peripheral levels of the health system (the community and the district) and fully involves the district health team. There are no specific malaria staff at that level”.

According to Kengaya-Kayondo, there are three outstanding issues.

“Firstly, the distribution of health resources needs to be changed, so the bulk is made available at the community level. Secondly, we lack funding to speed up research on the use of artemisinin combinations (ACTs). And thirdly, the resource issue requires a major shift in how governments spend their health budgets and how donors give aid.”