Community-Based Treatment of Pneumonia (“CBT of P”)

Technical basis, USAID strategy and the role of PVOs

Child Survival and Health PVO Grants RFA Orientation14 September 2004

Global burden of disease

• Mortality– 21% of under-5 deaths are due to pneumonia– 2 million under-5 deaths each year

• Potential lives saved– 1.3 million of these deaths are preventable– 577,000 lives could be saved by antibiotics

alone

Lancet, July 2004

Annual child deaths from pneumonia, malaria and diarrea by WHO region

WHO 2000

Early childhood infections and growth

Kg

0 3 6 9 12 15 18 21 24 27 30 33 36

2

3

4

5

6

7

8

9

10

11

12

13

14

15

KEYARI – Acute Respiratory InfectionD – Diarrhea M – MeaslesFEVER – Fever

AGE IN MONTHS

Adapted from MATA, 1975

ARI

ARI

ARIARI

ARI

ARI

ARI

ARI

ARI

ARI

ARIARI

ARIARI

ARI

ARI

M

D

DD D D DDDD

DFEVER

D DD D

D

D D

DD

D

Children with ARI symptoms taken to a health care facility

Global LAC SSAANE E&E

Source: Trends are estimates based on Demographic and Health Surveys, 1985-2000.

Unmet need for CBT

• 28% die without receiving any care outside the home

• Only 10% receive quality care in facilities

Evidence for CBT

• Meta-analysis (Lancet 2004)– Infant mortality

• All-cause reduced by 20%• Pneumonia-specific reduced by 36%

– Under-5 mortality • All-cause reduced by 24%• Pneumonia-specific reduced by 36%

• Cost-effectiveness (MBB Tool 2004)– Additional cost/person/year = $0.09 (Ethiopia)

Simplified algorithm

Child with ARI sx’s brought to CHW

Child <2 months Child 2-59 months

Referred to facility

Severe pneumonia

Pneumonia URI

AdviceCotrimoxazole

“(Virtually) Every child with pneumonia in a malaria-endemic area should

receive effective treatment for malaria as well.” (CDC, UNICEF)

Malaria/pneumonia symptom overlap

“Fever in past 48 hours” (= malaria)

“Cough with rapid breathing” (= pneumonia)

Afebrile pneumonia

Nepal case study

Pneumonia cases treated by CHWs and health facilities in four program districts

25

5751

29

43

0

40000

80000

120000

160000

200000

1995/96 1996/97 1997/98 1998/99 1999/00

Year

Num

ber

of C

ases

0

10

20

30

40

50

60

% of E

xpected Cases

Pneumonia Cases Treated by CHWs

Pneumonia Cases Treated at HFs

% of Expected Pneumonia Cases Treated

<20% 1991/92

62% 2000/01

Quality of care: Correct dosing of cotrimoxazole

82

84

86

88

90

92

94

96

98

1998 1999 2000

% Correct Dose

Senegal case study

Results

• Appropriateness of management– 95% of pneumonia cases correctly classified– 97% correctly treated– 69% of severe cases appropriately referred

(additional 22% received cotrimoxazole)

• Effect on care-seeking– Nearly twice as many pneumonia cases were

treated in intervention areas than in control areas (185 vs. 96 per 1000 population)

WHO/UNICEF Joint Statement

“CHWs can be trained to assess sick children for signs of pneumonia; select appropriate treatments;

administer the proper doses of antibiotics; counsel parents on how to follow the recommended treatment regimen; follow-up sick children; and refer them to a

health facility in case of complications.

There is strong scientific and program evidence to support the effectiveness of this approach.”

WHO/UNICEF Joint Statement, “Management of Pneumonia in Community Settings,” May 2004

USAID’s CBT strategy: Global goals

1. Increase awareness and funding for CBT of pneumonia

2. Achieve >25% coverage of target population with high quality care in >10 of the 42 high-mortality countries by 2010 (“10 by 10” Initiative)

3. Contribute to evidence base for related interventions: integrated approaches to pneumonia and malaria, treatment of severe pneumonia, treatment in HIV high-prevalence areas, treatment of pneumonia and sepsis in children <2 months, private sector approaches

Regional goals

• Africa– The Big 3 (Nigeria, Ethiopia, DRC)– W. Africa through regional approach– Other countries as opportunities arise

• Southeast Asia– Cambodia

• South Asia– Bangladesh and India

• Latin America– Remote regions as appropriate

Country criteria

• Willingness of MOH to consider changing policy or to explore community-based approaches to improving access to treatment of pneumonia

• Existence or emergence of an appropriate cadre within the community or at the peripheral facility level with potential for large-scale implementation (e.g., greater than 25% of the populations at greatest risk)

• Functional drug management system at the peripheral level, or potential for improvement

• Adequate mechanisms for training, supervision and monitoring, or potential for improvement

• Poor access to health services or poor quality and utilization of services• High burden of disease as a proportion of under-5 mortality• Important contributor to global under-5 mortality• Potential for influencing other countries• Potential for contributing to an evidence base for related interventions• Availability of appropriate donor and implementation partners

Country typology

• Countries that are willing to proceed and that only require operational guidance and funding (e.g., Tigray)

• Countries that are not yet convinced, but might be satisfied by evidence from within their region (e.g., Benin)

• Countries that are not yet convinced, and will require local proof based on a demonstration project (e.g., Mozambique)

• Countries that are opposed, and which will require extensive evidence from other countries and advocacy before even agreeing to a demonstration project

Existing early country efforts

• Bangladesh• Benin• Cambodia• DR Congo• Ethiopia• Haiti• India• Madagascar

• Malawi• Mali• Mozambique• Nigeria• Senegal• Uganda• West Africa• Zambia

Role of PVOsMOH

Community

PVOs

USAID

Synergy !COREGroup

BASICS 3HARPRPM+

How can USAID help?

• Support for policy change (with WHO, UNICEF, World Bank, local USAID Mission)

• Technical assistance for programming, M&E, tools

How can CORE help?

• Sharing member experiences

• Drafting of a field guide for program managers

• Global, regional and national advocacy