HOME BASED MANAGEMENT OF FEVER STRATEGY IN UGANDA

HOME BASED MANAGEMENT OF FEVER STRATEGY IN UGANDA An Assessment study on the Performance of Home Based Management of Fevers Strategy among the under 5 Children in Kabarole and Luwero Districts of Uganda Supported by African Health Research Fellowship Program Investigators Charles Wycliffe Matsiko, Nelson Musoba, Julius Lutwama, Robinah Kaitiritimba and Jessica Jitta. July, 2007

TABLE OF CONTENTS ACKNOWLEGEMENTS...iii ACRONYMS... iv 1.0 INTRODUCTION... 1 1.1 Background to the study... 1 1.2 Malaria Control and Prevention... 1 1.2.1 The concept of Home-Based Management of Fever (HBMF)... 2 1.3 Objectives of the Study... 3 1.3.1 Specific objectives... 3 2.0 STUDY METHODOLOGY... 4 2.1 Sample size and selection... 4 2.2 Sampling procedure... 4 2.3 Sampling Technique... 5 2.3.1 Key Informant Interviews (KII)... 5 2.3.2 Focus Group Discussions (FGDs)... 5 3.0 STUDY FINDINGS... 6 3.1 Respondents Profile... 6 3.2 Performance of Home Based Management (HBM) of Fever Strategy... 8 3.3 Policy implications of the HBM of fever Strategy... 14 4.0 CONCLUSIONS AND RECOMMENDATIONS... 16 ii

ACKNOWLEGEMENTS The study team would like to acknowledge the contributions of many friends and officials who contributed in one way or another to make this study a success. We are greatly indented to the people of Luwero and Kabarole for accepting to give us this invaluable information. Special thanks go to the District Health Officers and their teams in the two districts who guided the study team during the study period. Thanks to African Health Research Forum for supporting both the program and the study. Investigators: Charles Wycliffe Matsiko 1, Nelson Musoba 2, Julius Lutwama 3 Robinah Kaitiritimba 4, Jessica Jitta 5 1 Human Resources Division, Ministry of Health 2 Public Private Partnership, Ministry of Health 3 Uganda Virus Research Institute 4 Uganda National Health Consumers Organization 5 Child Health Development Centre iii

ACRONYMS FGD HBMF HIS HMIS IPT ITN KII MOH RBM WHO Focus Group Discussions Home Based Management of Fever Health Information System Health Management Information System Intermittent Preventive Treatment Insecticide-Treated Net Key Informant Interviews Ministry of Health Roll Back Malaria World Health Organization iv

EXECUTIVE SUMMARY An Assessment study on the performance of Home Based Management of Fevers Strategy among the under 5 Children was conducted in Kabarole and Luwero Districts of Uganda during the period January to February 2007. The study was conceived after realizing that prompt access to effective anti-malarial treatment is one of the major strategies for reducing the intolerable burden of malaria. Prompt access means having treatment available as near the home as possible - either in the community or in the home itself. In Africa, where the mortality burden from malaria is greatest, children can die before they reach the health services, so having treatment available near the home is very important and is a major strategy for this region. The general objective of the study was to assess the performance of HBM of fever and the community s response towards the strategy. This study was part of the research component of the African Health Research Leadership Training Programme for Uganda Team A. The specific objectives of the study were to: 1. Assess the performance of home based management of fever as a strategy 2. Assess Community Response to home based care for malaria 3. Establish Policy implications of the home based management of fever on communities. The study adopted a cross-sectional quantitative and qualitative study design. The quantitative study design employed semi-structured questionnaire which targeted mainly the household heads of children below five year who had accessed and benefited from the services of the Community Drug Distributors in two selected parishes of two subcounties in the districts of Luwero and one sub-county in the district of Kabarole. Key Findings The study findings indicate that a total of 410 households were recruited in this study and they came from three sub-counties of Katikamu and Nyimbwa in Luwero district and Mugusu sub-county in Kabarole district. In the assessment of the performance of HBM most respondents 220 (57.9%) reported that the strategy has worked well, 84 (22.1%) reported that the strategy was fairly implemented while 55 (14.5%) reported that HBM strategy worked moderately well. Conclusions Home Based Management of Fever in Kabarole and Luwero has worked well as suggested by 58% of the respondents in both districts. On the other hand, 72% of the respondents rated the strategy between moderately well to very well. v

The HBM strategy has to a greater extent influenced both the boundary partners and strategic partners where, the programme has worked well. Community involvement in drug distribution and monitoring has revealed the importance of early health seeking behaviour and referral. Community mobilization and Training have improved awareness and net works. Recommendations It is recommended that two people per village be trained, supported and motivated to work as community health workers to carry on the work of community volunteers. This will help in scaling up control measures established in communities by HBM programme. Government should put more effort and resources in improving the quality of HMIS and access to health services before, the utility of HMIS case and death reports for monitoring disease trends could be assessed. It is recommended that government scales up the strategy through training of health workers, provision of medicines and other supplies and community capacity building to meet the targets set. vi

1.0 INTRODUCTION 1.1 Background to the study Malaria is the most serious public health problem in the world. About 40% of the world s population and over half of the world s countries are at risk of malaria, with 9 out of 10 cases occurring in sub-saharan Africa (RBM, 2000). Generally, malaria contributes to widespread human suffering, particularly among the poorest in the world. It kills over one million people each year, about 3,000 per day. The majority of victims are children who die because they lack access to health care, life-saving drugs and treated mosquito nets. The P. falciparum infections are thought to result in approximately 200 million clinical events and 1 million deaths annually, approximately 75% of which are children (about 3 out of every 4). It is also a major factor contributing to maternal deaths as well as low birth weights. Malaria remains one of the world s greatest childhood killers and is a substantial obstacle to social and economic development in Africa (WHO 2000). The overwhelming bulk of the world s malaria burden rests upon the population of Sub-Saharan Africa because of the unique coincidence of expanding human populations, weak health systems, the world s most effective vector mosquito species and environmental conditions ideal for transmission (Killeen et al. 2002). In Uganda, it is still apparent that of the total deaths, 23% and 11% occur among children under 5 years in high and low transmission areas, respectively (MoH 2001). Malaria specific death rate among the under 5s is 37/1,000 and 18/1,000 in high and low malaria endemic areas in Uganda respectively, which translates to about 70,000-110,000 child deaths annually. With acute disease a child may die within 24 hours. The disease kills children often in combination with other diseases. Among the children who survive, malaria drains the vital nutrients, impair their physical, intellectual development and school attendance, leading to childhood anaemia, reduced growth (stunting) and mental retardation. In many areas the children may get an average of 6 episodes of malaria each year. Severe malarial anaemia results in a case fatality rate of 8-25% among paediatric admissions. Malaria is responsible for up to 70% of out-patient attendances and over 50% of in-patient admissions in the under 5s. 1.2 Malaria Control and Prevention Prevention and reduction of mortality and morbidity from malaria are the main objectives of the malaria control activities in the country. These objectives can be achieved through prompt diagnosis and appropriate treatment of disease, as well as vector control, particularly reduction of the vector population at the breeding sites.

The risk of malaria infection exists in most of the 56 districts in the country. However, the control and treatment of malaria in Uganda is far from optimal. This is due to the lack of public-sector organization and resources and the poverty of individual households. The spraying of residual insecticide on the interior surfaces of houses requires large amount of insecticide that must be re-applied annually. The insecticidetreated mosquito nets (ITNs) technology requires major investment, with costs only partly recuperated from the users (Chavasse et al., 1999). ITNs are not readily available, although in some communities people are willing to pay for them. In addition, the community manages malaria through indigenous practices (herbs, clearing of bushes, burning of cow dung etc.), the impact of which is not known. 1.2.1 The concept of Home-Based Management of Fever (HBMF) Prompt access to effective anti-malarial treatment is one of the major strategies for reducing the intolerable burden of malaria. Prompt access means having treatment available as near the home as possible - either in the community or in the home itself. In Africa, where the mortality burden from malaria is greatest, children can die before they reach the health services, so having treatment available near the home is very important and is a major strategy for this region. Scaling up of HMM means ensuring that quality anti-malarials are easy to obtain and adequately distributed everywhere. Not only must people be able to access effective treatment within 24 hours, but they must take the correct dose and comply fully with the treatment (TDRNEWS, 2002). Recognition, and early appropriate treatment, of febrile illness in children is the basis of malaria control in endemic countries. In Africa, the majority of children with fever are treated at home, so reaching the home and community more effectively with anti-malarial treatment is likely to have an impact on malaria control. Increasing the availability, and improving the use, of effective anti-malarials for the treatment of suspected malaria at home has the potential to reduce the time between onset of symptoms and delivery of treatment, and could result in a reduction in malaria morbidity and mortality (TDR, 2001). Uganda was one of the first countries to establish a national policy for home based management of malaria, and is now taking the idea to full scale. It is also scaling up a large information programme to encourage mothers to treat their children properly at home. Home care is defined as the provision of health services by formal and informal caregivers in the home (MoH, 2002). The strategy is to provide rapid, appropriate, effective and free malaria treatment to the people who need it most--mainly mothers caring for their sick children. Instead of walking miles to reach a health centre and then waiting for hours, mothers will soon be able to knock on a neighbour's door to get the help they need. With Home Based Management, every village or community will have at least one volunteer drug distributor trained to recognize the symptoms of malaria and provide the appropriate drugs to treat it. The volunteers are mainly elected from within their communities and are committed to making a difference. 2

Uganda first tested the method in three districts. As a first step, the MoH, supported by the World Health Organization (WHO), decided to start a program of free distribution of unit-dosed, prepacked anti-malarial treatments (combination of Chloroquine and Sulfadoxine-Pyrimethamine (CQ/SP) for children under 5 years of age (2 sizes: 6 months to 2 years and older than 2 to 5 years) through communities and the public health sector. In the three districts of Uganda where the Home Based Management scheme was initially evaluated, the reaction from volunteers and villagers was overwhelmingly positive. The test was then continued in 10 selected districts, and in 2002 on Africa Malaria Day (April 25th) HBMF rolled out as an official national treatment policy for malaria. So far the program has been implemented in 30 out of 56 districts. The first follow-up survey in July 2003 indicated a significant improvement in timeliness and accessibility of adequate malaria treatment in the target population with close to 60% of children under 5 in the HBMF implementation areas receiving treatment within 24 hours, and thereby reaching the Abuja target. With support from the Global Fund, implementation of HBMF will be scaled up in 2004 to reach all districts. After the start of artemisinin-based combination treatment (ACT) at health facility level, a gradual introduction of these drugs at community level is planned 1.3 Objectives of the Study The general objective of the study was to assess the performance of HBM of fever and the community s response towards the strategy. 1.3.1 Specific objectives The study had the following specific objectives. 4. To assess the performance of home based management of fever as a strategy 5. To assess Community Response to home based care for malaria 6. To establish Policy implications of the home based management of fever on communities. 3

2.0 STUDY METHODOLOGY The study adopted a cross-sectional quantitative and qualitative study design. The quantitative study design employed semi-structured questionnaire which targeted mainly the household heads of children below five year who had accessed and benefited from the services of the Community Drug Distributors in two selected parishes of two subcounties in the districts of Luwero and one sub-county in the district of Kabarole. 2.1 Sample size and selection The sample size was calculated using the Kish and Leslie (1965) formula for sample size calculation. An estimated fifty percent (50%) prevalence of outcome was used in calculating the sample size as it maximizes the sample. At 95% confidence level, and with a 5% error term, the total survey sample size was 410 respondents. Sample size formula n = Z 2 pq e 2 Where; Z is the value from statistical tables, which contain the area under the normal curve, at 95% confidence level as 1.96. p is the estimated prevalence of outcome q is (1-p) e is the desired level of precision (or acceptable error), taken at 5% Making a total sample size of 400 respondents 2.2 Sampling procedure Two districts where the program was implemented were selected purposively, two sub counties in Luwero and one sub-county in Kabarole district and two parishes in each sub county were selected randomly, from a listing of villages in the selected parishes, four villages will be selected in Luwero and two villages in Kabarole randomly from which respondents for this study were selected. Inclusion Criterion All households were eligible for this study, and were selected randomly. Household heads were taken as respondents for this study. In cases where the household heads were not available, main caretakers in households were interviewed. The team selected a sample of communities representative of two districts one where HBM program has worked and the second one where the programme has not worked well. A questionnaire was prepared for community members and health unit staff. Multi-stage and 4

Simple random sampling were employed in the study. To ensure this, multi-stage random sampling was employed to select a representative sample of sub-counties and parishes. The lists of units (parishes and communities /LC Is) at each level of sampling were obtained from the district health office. Using these criteria, Kabarole in Western Uganda and Luwero in Central were the districts of study. 2.3 Sampling Technique Lists of parishes were obtained from the two (2) districts purposively selected Kabarole and Luwero. Three sub-counties were selected two in Luwero and one in Kabarole. Names of the parishes in each in each of the selected sub-counties were written on pieces of paper. These papers were then folded evenly and put in a container, shaken for some time and displayed on table. Each member of the study team was asked to pick one piece of paper at a time containing a name of the parish selected. A total number of parishes selected in each sub-county were included in the sample. The team selected at least 1/3 of the parishes in each selected sub-county. Furthermore, the technique was repeated to select at least 1/3 of the communities (LC Is) in each selected parish. With the help of the health staff guides, the study teams purposively selected households participants in each selected community. 2.3.1 Key Informant Interviews (KII) In-depth interviews with key stakeholder representatives selected in agreement with the district health staff were done using checklists of questions. The interview guides were designed to stimulate discussions so that the interviews are interactive and highly participatory. 2.3.2 Focus Group Discussions (FGDs) Focus Group Discussions were organised with the stakeholders (women, men, volunteers and service providers) on the key issues raised in the proposal. Checklists of questions/ topics were developed to cover all the main issues. 5

3.0 STUDY FINDINGS This section of the report presents findings from the survey and interviews that were conducted in the 2 districts (Luwero and Kabarole) and at national level. The Policy implications of the findings are discussed where they are presented. 3.1 Respondents Profile Characteristics of households visited A total of 410 households were recruited in this study and they came from three subcounties of Katikamu and Nyimbwa in Luwero district and Mugusu sub-county in Kabarole district. The frequency distribution of the households covered by the study per sub-county is as indicated table 1. Table 1: Distribution of households covered by sub-county of residence Sub-county Frequency Percentage Katikamu 102 24.9 Mugusu 201 49.0 Nyimbwa 107 26.1 Total 410 100.0 The study covered 102 households in Katikamu, 201 in Mugusu and 107 in Nyimbwa. Each of these sub-counties has a health centre level III and a health inspector. It is this health centre III that provides drugs for malaria treatment at household level. These subcounties were selected by the district health officials together with the researchers at the time of data collection. Sex of the respondent Table 2 shows the sex of the respondents in this study. Out of 410 a total of 80 (19.5%) were male respondents while the female respondents were 330 (80.5%). Table 2: Sex of the respondents Sex Frequency (n=410) Percentage Male 80 19.5 Female 330 80.5 Total 410 100 The fact that the majority of the respondents were female (80%) is an indication that most of the male household heads go to work during day and only come back home in the evenings. Since the study was conducted during the day time, their female counterparts 6

were mainly at home and able to attend the interviews. Likewise, the women in Ugandan context were responsible for caring for children including provision of medical care. In this study, findings indicated that women were the ones responsible for providing medication provided by the HBM programme mainly because they were readily at home most of the time. Education Table 3 shows the highest level of education attained by household heads that were present at the time of the study. Table 3: Education attainment for Household heads Education level Frequency (n=410) Percent None 72 17.6 Lower Primary (P1-P4) 87 21.2 Upper Primary (P5-P7) 149 36.3 Secondary 93 22.7 Tertiary 9 2.2 Total 410 100 The majority of the household heads had attained educational level of P5-P7 with a total of 149 (36.3%) followed by secondary education 93 (22.7%) and Lower Primary (P1-P4) with a total of 87 (21.2%). These findings were not surprising because, the majority of women that have reached secondary school level of education are engaged in gainful employment by Ugandan standards. The fact that the majority (36%) were found at home at the time of the study is an indication that most likely these were non-working mothers who form the bulk of the rural women in Uganda. Marital Status Table 4 shows the marital status of the respondents. A total of 327 out of 410 (79.8%) were married. A total of 36 (8.8%) had never married, 25 (6.1%) had separated and 19 (4.6%) had lost their partners as indicated in the table. Table 4: Marital status of the Household heads Marital Status Frequency Percent Married 327 79.8 Never Married 36 8.8 Widowed 19 4.6 Divorced 3 0.7 Separated 25 6.1 Total 410 100 These results indicate that most of the household heads found at home during the time of the study were married (79%). In Uganda, most married women who are not engaged in gainful employment are married. Their husbands go to work in towns leaving their 7

spouses to care for children and attend to other house chores. However, the study revealed interesting results that 36 (8.8%) of the respondents had never married and yet they had children as single parents. 3.2 Performance of Home Based Management (HBM) of Fever Strategy Knowledge of Home Based Management of Fever Performance of the strategy was assessed by testing the knowledge of the respondents. Household heads were asked as to how long ago they had heard about the home based management of fevers. Responses from this assessment were analyzed as indicated in table 5. Table 5: Knowledge of Home Based Management of Fever by time period Time period Frequency (n=410) Percent Less than 2 months 126 30.7 2 6 months 247 60.2 More than 6 months 36 8.8 Don t remember 1 0.3 Total 410 100 Out of the 410 household heads 247 (60.2%) had heard about HBM in the previous 2 to 6 months, 126 (30.7%) had heard it in the previous less than 2 months, while 36 (8.8%) had heard about the programme in more than 6 months. The study further revealed that 1 (0.3%) could not remember the time period although the respondent had heard about the strategy. The fact that over 60% of the household heads had heard about HBM is in itself an indication that the programme had reached most of the community members. The onus was on the people themselves to accept the guidance given to them by the health workers to fight the disease at the household level. On the other hand however, health workers have a duty to keep their messages high on the agenda, so that every person in the community is informed of what is happening at any one time. The challenge observed in the two districts is that recording and reporting of malaria cases is still a problem. This is not unique to Uganda alone because WHO (2005) reported that in most countries, reported case rates represent only part of the actual total number of malaria cases, since many people are treated at home or in private facilities that do not report to the national HMIS. The report further adds that if HIS reporting is reasonably consistent and complete over the years, trends in the reported cases might give some indication of the local trend in the malaria burden. Coverage by Community Drug Distributors In order to assess the work done by the Community Drug Distributors (CDD), household heads were asked as to whether some one had ever talked to them about the HBM programme. Analysis out of this assessment has been presented in table 6. 8

Table 6: Coverage by Community Drug Distributors Frequency Percentage (n=394) Somebody ever talked to me about the 322 81.7 programme Nobody has ever talked to me about the 72 18.3 programme Total 394 100 Out of 394 household heads who answered this question, 322 (81.7%) reported having been talked to by some one about HBM strategy. A total of 72 (18.3%) reported that nobody had ever talked to them about the programme. This implies that this category knew about HBM although they did not learn it from the drug distributors. The strategy used a number of approaches to the reach the communities. Drug Distributors were used as part of the strategy but in other instances, radio programmes were conducted on different FM radios in the country. In other instances, Information Education and Communication (IEC) materials were developed and sent to communities by the ministry of health and therefore, one could have picked the message from other sources other than the drug distributors. Reported children suffering from fever in the previous two weeks to one month Household heads were asked whether any child in their community suffered from fever in the last two weeks to one month. Of the 410 household heads in the three sub-counties, the majority 405 (98.8%) had seen a child in their community suffering from fever as indicated in table 7. Table 7: Presence of children in the community suffering from fever in the last 2 weeks to 2 months Suffering from fever Frequency (n=410) Percentage Children have suffered from fever 405 98.8 Children have not suffered from fever 5 1.2 Total 410 100.0 Further analysis was done on all persons that had responded to the question that inquired whether one had seen a child in their community suffering from fever. To establish as to whether the sickness was malaria, household heads were further asked to mention the symptoms of the illness. Responses out of this analysis were summarized as indicated in table 8. 9

Table 8: Symptoms of fever/malaria as seen by household heads Symptom Frequency Percent Fever/Hot body 386 94.1 Cough 169 41.2 Difficulty in breathing 74 18.0 Diarrhea 94 22.9 Blood in stool 1 0.2 Eye disease 20 4.9 Vomiting everything 193 47.1 Convulsions 41 10.0 Unconscious 39 9.5 Yellow eyes 34 8.3 Failure to feed 216 52.7 Others 20 4.9 Percentages do not add up to 100 because of multiple responses. The majority of children under 5 years in the study presented with raised temperature as shown by 386 (94.1%) of the respondents. A total of 216 (52.7%) were reported failing to feed, 193 (47.1%) were reported vomiting everything, while 169 (41.2%) presented with cough. Most of the symptoms identified pointed to malaria as the commonest cause of fever in the districts of study. Malaria control Policy in Uganda provides for handling all fevers in the community as if it was malaria before one carried out diagnostic tests. It has been recently reported by the WHO (2005) that Africa remains the region that has the greatest burden of malaria cases and deaths in the World. The WHO asserts that in the year 2000, malaria was the principle cause of around 18% that is 803,000 (uncertainty range 710,000 896,000) of deaths of children under 5 years of age in Africa south of the Sahara. It is further reported that other countries in Africa such as Egypt and Morocco, have only residual malaria transmission and occasional imported cases in comparison to Uganda where malaria is still endemic. About people trained in the community who provide simple treatment at home Household heads were asked to mention if they were aware of any people trained in community who provide simple treatments at home. Responses out of this analysis is as show in figure 1 10

Figure 1: About people who are trained in the community to give simple treatment (n=410) Don't Remember 2 8 Not aware of people trained 17 70 Aware of people trained 81 332 0 100 200 300 400 Respondents (No and Percentage) Frequency Percent Most people 332 (81%) were aware of the people trained in the community who provided simple treatments at home. These were referred to as Community Drug Distributors (CDD). Only 70 (17%) household heads were not aware of these CDD in their communities and 8 (2%) could not remember. Qualitative information revealed that although the drug distributors are known to majority of the residents, they are not working on full time basis. These are volunteers that have been given some training on identifying fever cases and provide some treatment as directed by a physician. They are also supposed to refer cases they cannot handle at the community level. Being volunteers in the community, the CDDs have other work they do to earn a living. This could explain why 17% of the household heads were not aware of their existence in their communities. The study further explored the rate of interaction between the household heads and the community drug distributors. To do this, respondents were asked to mention how many times the household heads had visited the CDDs. Responses for this question were summarized and are as indicated in figure 2. 11

Figure 2: Number of times Household heads had visited CDD (n=410) Not sure 35 8.5 Visited three times 63 15.4 Visited twice 78 19 Only once 186 45.3 Not visited 1.2 5 Many times 43 10.5 0 50 100 150 200 250 Household heads (No and Percentage) Frequency Percent Most household heads had visited the community drug distributor at least once 168 (45.3%) as far as they could remember. A small number 5 (1.2%) reported that they had not visited a CDD. This implies that almost every child in these communities has at least suffered from malaria during the recall period of 2 weeks to 1 month. Number of times CDDs have visited households in the previous 2 months Respondents were asked to give information on the number of times the CDDs had visited them. Responses were analyzed and the summary is given in table 9. Table 9: Reported CDD visits by the Household heads (n=363) Time Range Frequency Percent None 11 3.0 1 to 3 times 128 35.3 4 to 6 times 72 19.8 7 to 10 times 35 9.6 More than 10 times 8 2.3 Don t remember 109 30.0 Total 363 100 Out of 363 respondents who responded to this question, the majority 128 (35.3%) reported CDDs having visited them once to three times. A total of 72 (19.8%) reported having been visited 4 to 6 times and 8 (2.3%) reported more than 10 times. This implies that the CDDs are doing their jobs as directed by the district health authorities. This is in line with the reports from the Luwero district which indicated that malaria is being controlled by the use of the drug distributors. 12

The programme started in October 2004. The district had 21 lower level local councils. The district sensitizing the DHT, then the district council and later identified 13 subcounties at that time. The CDDs were selected trained and then given registers and Homapak. The programme has done very well despite a few challenges here and there. (KI: District Health Office, Luwero). Advice related to preventing malaria Respondents were asked to mention if they ever asked advice related to preventing malaria from the community drug distributors. Out of 357 respondents that answered this question, the majority 191 ( 53.5%) reported having never asked for advise while 159 (44.5%) have asked for advise relating to prevention of malaria as shown in figure 3. Figure 3: Advice relating to prevention of malaria (n=357) Have never asked 53% Don't remember 2% Have asked 45% This finding is very important because this community strategy was taken to reduce the burden of malaria in Uganda. The country is one those African countries that have been working towards reducing the burden of malaria significantly. Literature reveals (WHO 2005) that at the Africa s summit on Roll Back Malaria in Abuja, Nigeria, in 2000, Africa s heads of state committed themselves to halving the burden of malaria by 2010 by achieving a 60% coverage of all at risk populations with suitable curative and preventive measures by 2005 and Uganda was one of them. It is now argued that few countries may have reached 60% target for coverage of access to prompt and effective treatment for ITN and IPT for pregnant women in the target year of 2005. 13

Table 10: How well HBM strategy has worked Performance Frequency Percent Very well 220 57.9 Moderately well 55 14.5 Fair 84 22.1 Poor 16 4.2 Very poor 5 1.3 Total 380 100 In the assessment of the performance of HBM most respondents 220 (57.9%) reported that the strategy worked well, 84 (22.1%) reported that the strategy was fairly implemented while 55 (14.5%) reported that HBM strategy worked moderately well. The fact that more than 70% of the people reported the strategy having worked very well and moderately well is a measure of success. The delivery of malaria-related services to populations at risk in both districts is being monitored by the district health system and other agencies involved in implementing control activities. Indicators of success include those being used at the national level by malaria control programme namely, the number of ITNs distributed or sold, ITN re-treatments provided, quantities of insecticides used for IRS and quantities of drugs supplied. 3.3 Policy implications of the HBM of fever Strategy The data presented in this report illustrates not only the progress made in Uganda in recent years with regard to malaria control but also identify several gaps and limitations in available data and challenges that require policy interventions. This section reviews the malaria situation and presents policy recommendation to improve the strategy. Influence on boundary and strategic partners The study notes that the HBM strategy has had great influence on the communities them selves, the leaders including local councils. It was also noted that the health workers including the health assistants that serve in these communities were directly influenced positively by this programme. There have been attempts to establish improved reporting system which is still a challenge at community level. At the district level both strategic and annual health sector plans now reflect activities that relate control and management of malaria. Surveillance systems that monitor the efficacy of locally used drugs have been set up. Results of disease surveillance are reported to the national level on weekly basis for information and action. This is in line with the report on the recent progress in monitoring of malaria in WHO countries. It is reported WHO (2005) that standardized high-quality drug efficacy surveillance is being promoted through sub-regional initiatives including East African Network for the surveillance of Ant malarial Drug Resistance. 14

At community level, the strategy has worker very well through the Village Health Teams (VHT) and community health volunteers who form the bulk of drug distributors and Community Own Resource Persons (CORPs). 15

4.0 CONCLUSIONS AND RECOMMENDATIONS 4.1 Conclusions Home Based Management of Fever in Kabarole and Luwero has worked well as suggested by 58% of the respondents in both districts. On the other hand, 72% of the respondents rated the strategy between moderately well to very well. The HBM strategy has to a greater extent influenced both the boundary partners and strategic partners where, the programme has worked well. Community involvement in drug distribution and monitoring has revealed the importance of early health seeking behaviour and referral. Community mobilization and Training have improved awareness and net works. 4.2 Recommendations It is recommended that two people per village be trained, supported and motivated to work as community health workers to carry on the work of community volunteers. This will help in scaling up control measures established in communities by HBM programme. Government should put more effort and resources in improving the quality of HMIS and access to health services before, the utility of HMIS case and death reports for monitoring disease trends could be assessed. It is recommended that government scales up the strategy through training of health workers, provision of medicines and other supplies and community capacity building to meet the targets set. 16