PAKISTAN BEST PRACTICE PNEUMONIA DEMONSTRATION PROJECTS
DRAFT PROPOSAL OF THE PNEUMONIA AND DIARRHEA WORKING GROUP1
in support of
THE UNITED NATIONS COMMISSION ON LIFE-SAVING COMMODITIES FOR WOMEN AND
CHILDREN
THE INTEGRATED GLOBAL ACTION PLAN FOR PNEUMONIA AND DIARRHOEA
April, 2013
THE CHALLENGE
In 2011, 352,000 children in Pakistan did not reach their 5th birthdays putting Pakistan
at #4 on the list of countries with the highest burdens of child mortality.
Pneumonia is
the single largest cause of death
among
children mortality
in Pakistan,
Causes
of under-five
in causing an estimated
70,000 (19%) under 5 deaths and around 7Pakistan
million episodes of sickness every year at an
2
enormous cost to childrenMeasles
and families.
11%
Diarrhea
While it is true that the majority of child
1%
pneumonia deaths can be
prevented with cost effective vaccines and low cost antibiotics,
Congenital
Pneumoni
anomalies
the pneumococcal vaccine
has just been introduced
in Pakistan in 2012 and only 50% of
a
2%
Meningitis In addition, Pakistan’s
19%antibiotics.
children with suspected pneumonia are treated with
3%
Prematurit
relatively low rates of exclusive
breastfeeding (37%), access
to improved sanitation
y
Birth
17%
(48%) and high rate of undernutrition
(42% children asphyxia
are stunted) are all factors
12%
contributing to the large number of child pneumonia deaths.3
coordinated action on these
averted taking Pakistan one
(MDG4).
1
4
With concerted and
Neonatal
Injuries
fronts
child pneumonia deaths could
sepsismost of the 70,000 5%
big 9%
step closer Other
to achieving Millennium Development Goal
21%
be
4
The Pneumonia and Diarrhea Working Group is chaired by UNICEF and the Clinton Health Access Initiative to
support the ten countries with the highest burdens of child mortality to implement Essential Medicines ScaleUp Plans to increase access to pneumonia, diarrhea and malaria treatment. The Projects are consistent with
the Declaration on Scaling Up Treatment of Diarrhea and Pneumonia in the Highest Burden Countries , endorsed
at the Child Survival, Call to Action in June 2012 and the pneumonia-related recommendations of the UN
Commission on Life-Saving Commodities for Women and Children and are in support of the United
2
See Committing to Child Survival: A Promise Renewed. Progress Report, 2012. UNICEF
3
See Pneumonia and Diarrhea. Tackling the Deadliest Diseases for the World’s Poorest Children, 2012, UNICEF
4
MDG4 requires a two-thirds reduction in the 1990 Child Mortality Rate by 2015
1
Countdown to 2015: Maternal, Newborn and Child Survival. Pakistan: The 2012 Report.
THE OPPORTUNITY
To accelerate progress to MDG4 in the three years remaining to 2015, the Government
of Pakistan is driving progress on both the prevention and treatment sides of the
pneumonia challenge.
Pakistan became the first country in South Asia to introduce the
pneumococcal vaccine in 2012 with GAVI support and a national Scale-Up Plan for
Essential Medicines for Child Health5 has been developed and lists the actions needed to
achieve universal coverage of essential medicines to treat pneumonia, diarrhea and malaria
in the context of integrated Community Case Management.
The Plan underscores the
importance of early diagnosis and treatment of pneumonia and acknowledges that many
child deaths in Pakistan are the result of failure to seek treatment in time.
On the
treatment side, the Plan highlights the need to improve the way both public and private
health providers respond to children with suspected pneumonia by training health workers
to diagnose and treat pneumonia with the recommended antibiotics.
Key elements of the Essential Medicines Scale Up Plan include:
PRIORITY ACTIONS TO SCALE UP ACCESS TO PNEUMONIA TREATMENT IN PAKISTAN
1) Educating Families &
2) Supporting Private
3) Supporting Public Sector
Caregivers
Sector Provision
Provision
-Teach families and
-Train private health
-Train and equip Lady
caregivers about pneumonia,
providers particularly GPs
Health Workers (LHWs) to
the seriousness of the
and chemists to better
diagnose and treat
infection, and how to
manage childhood pneumonia
pneumonia with amoxicillin
5
Das and Bhutta, Aga Khan University, Karachi, 2011
2
recognize the danger signs
(70% of sick children are
dispersible tablets
(fast breathing and chest
treated in the private
-Improve forecasting,
“indrawing”)
sector)
procurement and
-Increase the supply of
distribution of quality,
care outside the home from
quality, affordable amoxicillin
affordable amoxicillin
qualified health providers
dispersible tablets
dispersible tablets in the
quickly (currently 30% of
-Increase the relative
public sector
children with pneumonia are
affordability of amoxicillin
-Train and equip hospital
treated at home)
dispersible tablets compared
and facility staff to treat
-Educate families about
to other antibiotics (e.g.
severe pneumonia with
amoxicillin dispersible
cotrimoxazole) and other
recommended antibiotics and
tablets, how they work and
common pneumonia
oxygen where necessary
the importance of
treatments
-Upgrade facilities to
completing a full course of
-Reduce the costs of
diagnose and treat severe
treatment
pneumonia treatment
pneumonia including provision
-Introduce behavior change
(average $13 for outpatient
of pulse oximeters and
campaigns targeted to the
care, $71 for inpatient and
oxygen concentrators
most vulnerable families and
$235 for severe pneumonia
to the health providers who
in a hospital setting)6
-Encourage families to seek
treat the majority of
pneumonia cases
-Support programs that
empower mothers to
improve the health of their
children
4) Diagnostics
5) Local Manufacturing
6) Regulatory & Policy
--Increase use of easy-to-
--Work with pharmaceutical
Changes
use and effective respiratory
companies to increase local
-Recommend community
rate timers in public and
manufacturing,
case management of
private sectors
marketing and distribution
pneumonia with amoxicillin
-Increase use of pulse
of quality, affordable
dispersible tablets by Lady
oximetry in facilities
amoxicillin dispersible tablets
Health Workers as firstline
including Basic Health Units,
(currently only 1 registered
treatment
Rural Health Centers, Tehsil
dispersible tablet but many
-Disseminate pneumonia
and District Hospitals
syrups)
policies, standards and
-Ensure an adequate supply
-Offer fast track
treatment guidelines
of oxygen concentrators in
registration for locally
throughout the public and
facilities
manufactured amoxicillin
private health sectors
dispersible tablets that
-List amoxicillin dispersible
6
Das and Bhutta, 2011
3
meet quality and price
tablets on all Essential
targets
Medicines and Drug Lists
-Offer “umbrella brand
-Better monitor the quality
endorsement” for locally
of antibiotics being used to
manufactured amoxicillin
treat child pneumonia
dispersible tablets that
-Remove regulatory barriers
meet quality and price
to local pharmaceutical
targets
production of amoxicillin
- Work with manufacturers
dispersible tablets
to distribute dispersible
-Improve coordination across
amoxicillin tablets to rural
government programs and
areas
processes relating to child
survival (e.g. vaccines,
community case
management, HIV/AIDS,
malaria, nutrition, newborn
etc)
BEST PRACTICE PNEUMONIA DEMONSTRATION PROJECTS
To support the introduction of the pneumococcal vaccine and the implementation of the
Scale-Up Plan, we propose that Best Practice Pneumonia Demonstration Projects be
considered in Pakistan.
By combining the most effective pneumonia prevention, diagnosis
and treatment interventions in geographic areas with the highest concentrations of child
pneumonia deaths, the Projects will seek to demonstrate how to accelerate child
pneumonia mortality reductions and achieve efficiencies in the delivery of healthcare to
children through better coordination across programs.
The Projects will also provide the
Government with an opportunity to implement the recommendations of the United
Nations Commission on Life Saving Commodities for Women and Children as they relate
to amoxicillin dispersible tablets, ORS, zinc and potentially other commodities (e.g.
chlorhexidine and injectible antibiotics to reduce newborn infections).
Target regions could be selected from
those
that
will
introduce
the
pneumococcal vaccine; from those that
have
the
highest
concentrations
of
under 5 deaths, and/or from those
that are priorities for the introduction
of
integrated
Management.
Community
Case
The Government may
4
prefer a mix of sites to test different approaches and evaluate the outcomes.
Of
Pakistan’s four Provinces, Sindh and Punjab have the highest concentrations of under 5
deaths.
Punjab Province has a population of 91 million and a Child Mortality Rate of 97
and Sindh Province has a population of 36 million and a Child Mortality Rate of 101.7 In
addition Khyber Pakhtunkhwa might also be considered.
It was the site of the
groundbreaking trial that demonstrated that Lady Health Workers8 could effectively treat
children with severe pneumonia at home with amoxicillin (compared to the standard
practice of giving one dose of cotrimoxazole and referral to a hospital).9 A further study
in the same area of the Khyber Pakhtunkhwa found that families incurred much lower
costs when their children were treated by Lady Health Workers ($1.46 on average
compared to $7.60 for referred cases) leading the researchers to conclude that,
“expanding severe pneumonia treatment with oral amoxicillin to community level could
significantly reduce household costs and improve access to the underprivileged population,
preventing many child deaths.”10
For maximum impact, it is important that the Projects: (a) be at significant scale, (b)
better coordinate the delivery of the pneumococcal vaccine with integrated Community
Case Management of pneumonia and diarrhea, (c) stimulate the development of local
manufacturing of amoxicillin dispersible tablets, (d) target the providers of pneumonia
treatment who care for the majority of sick children, (e) test best practice approaches
to the diagnosis of pneumonia in a way that improves outcomes and reduces healthcare
costs, (f) test new innovations in pneumonia prevention, diagnosis and treatment,
including respiratory rate counters, pulse oximeters, oxygen concentrators and userfriendly packaging of amoxicillin dispersible tablets and g) rigorously and independently
evaluate impact.
Specifically the Projects in Pakistan could:
1. Education and Care Seeking

Increase awareness of the danger signs of pneumonia among families and caregivers
(targeting the health care decision makers in families)

Encourage families to seek medical care quickly if a child displays these danger signs

Explain to families the importance of having children immunized with the measles,
Hib and pneumococcal vaccines
7
Pakistan Demographic and Health Survey 2006-07
8
Established by Prime Minister of Pakistan, Benazir Bhutto, in 1994, 110,000 Lady Health Workers now reach
70% of the country’s rural population and are employed by the Federal Government.
9
Bari et al, Community Case Management of Severe Pneumonia with Oral Amoxicillin in Children Aged 2-59
Months in Haripur District, Pakistan: a Cluster Randomised Trial. The Lancet, November 19, 2011, Volume
378.
10
Sadruddin et al. Household Costs for Treatment of Severe Pneumonia in Pakistan, American Journal of
Tropical Medicine and Hygiene, 87, 2012
5

Educate families about amoxicillin dispersible tablets – what they do and how
important it is to complete a course of treatment

Reduce the costs of seeking care for suspected pneumonia through provision of
free public services and where appropriate incentives (e.g. vouchers, conditional
case transfers) for seeking care from private providers
2. Prevention

Increase coverage of the measles, Hib and pneumococcal vaccines, particularly
amongst the most vulnerable children

Offer information to families about pneumonia prevention and other healthy
behaviors at the point of vaccination (e.g. exclusive breast feeding, proper child
nutrition, hand washing with soap, reduction of household air pollution etc)

Distribute select prevention and treatment commodities, where appropriate, at
the point of vaccination (e.g. nutritional supplements for severely malnourished
children, Vitamin A, ORS, zinc supplements, chlorhexidine, soap etc)

Maximize uptake of prevention commodities with proven strategies (e.g. free
trials, time payments, rights to return and rights to stop payments) 11
3. Treatment

Introduce quality, affordable amoxicillin dispersible tablets, locally manufactured
where possible

Train and equip frontline health workers in both the public and private sectors to
better manage childhood pneumonia with amoxicillin dispersible tablets

Provide easy-to-use respiratory rate counters to health providers

Train frontline health workers to refer very sick children to facilities where
community case management is not appropriate and empower them to support
families to seek treatment in facilities (e.g. by reducing transportation costs)

Train facility based staff to effectively treat children with pneumonia including
better access to pulse oximetry and oxygen

Introduce community-based monitoring of public and private healthcare providers
to improve service utilization and health outcomes for children 12
11
David Levine and Carolyn Cotterman found large increases in uptake of an improved cookstove (from 5% to
45%) among residents of Kampala after free trial, time payments, the right to return the stove and the right
to stop the payments were introduced as part of the offer. See What Impedes Efficient Adoption of
Products? Evidence from Randomized Variation in Sales Offers for Improved Cookstoves in Uganda, Working
Paper Series, Institute for Research on Labor and Employment, UC Berkeley, 2012
12
Martina Björkman and Jakob Svensson found large increases in utilization of public primary health care services
and a 33% reduction in child mortality in communities that held service providers accountable for the quality of
care provided in a randomized field experiment conducted across 50 communities in 9 districts in Uganda. See
Power to the People: Evidence from a Randomized Field Experiment on Community-Based Monitoring in Uganda,
forthcoming
6
4. Innovation

Test the introduction of innovations to improve the diagnosis of pneumonia (e.g.
respiratory rate counters), the diagnosis of hypoxemia (e.g. pulse oximetry), the
treatment
of
concentrators)
pneumonia
and
(e.g.
adherence
rapid
with
acting
antibiotic
bronchodilators
treatment
(e.g.
and
oxygen
user-friendly
packaging of amoxicillin and simple, clear instructions for caregivers)
5. Impact

Rigorously and independently monitor and measure impact on treatment outcomes
and healthcare costs of the various approaches
POTENTIAL PARTNERS
The most effective investments in terms of children’s lives saved will be those that
combine key demand, supply and distribution elements at scale in the districts with the
greatest number of child pneumonia deaths and mobilize the right set of public and
private partners to drive uptake of interventions on both the prevention and treatment
sides – working together for collective impact.13
for the Demonstration
To maximize collective impact, partners
Projects should include
all relevant levels of Government,
organizations driving new vaccine introduction and those with experience in scaling-up
access to essential medicines and integrated community case management.
Projects could
build on the work of child health programs and partnerships already active in Pakistan
including the Lady Health Worker Program and those supported by Save the Children,
UNICEF, WHO, USAID, NORAD, CIDA and DfID.
Other potential partners include:
Absolute Return for Kids14, Abt Associates, Aga Khan Foundation, BHP Billiton, Bill and
Melinda
Gates
Foundation,
Center
for
Health
and
Population
Studies,
Children’s
Investment Fund Foundation, Clinton Health Access Initiative, College of Family Medicine,
Dow University of Health Sciences, FHI-360, GAVI, GFATM, Greenstar Social Marketing,
GSK, International Red Cross, JHPIEGO, John Snow Inc, MCHIP, National Rural Support
Program, Pakistan Broadcasting Corporation, Pakistan Pediatric Association, Pakistan
Medical Association, Pakistan pharmaceutical companies (e.g. ATCO Laboratories, Genix
Pharma,
13
Macter
International
and
ZAFA
Pharmaceutical
Laboratories),
Pakistan
Mark Kramer and John Kania argue that large-scale social change requires broad cross-sector coordination and
that substantially greater progress could be made in alleviating many of our most serious and complex social
problems if nonprofits, governments, businesses, and the public were brought together around a common agenda
to create collective impact. See Stanford Social Innovation Review, Winter 2011
14
ARK is currently investing in an integrated diarrhea prevention and treatment project in Zambia involving
introduction of the rotavirus vaccine, access to ORS and zinc and other interventions. This is one of the few
projects aiming to increase the number of children’s lives that can be saved by coordinating new vaccine
introduction with access to treatment
7
foundations (AHK Resource Center, Aman Foundation, Mahvash and Jahangir Siddiqui
Foundation,
Pakistan
Poverty
Alleviation
Fund,
Adamjee
Foundation
and
Engro
Foundation), PATH, Punjab Medical College, PSI, Rural Support Programmes Network,
Sustainable Peace and Development Organization, World Vision International and World
Bank.
This proposal was prepared by the Members of the Amoxicillin Sub-Group of the
Pneumonia and Diarrhea Working Group including UNICEF (Chair), Clinton Health Access
Initiative, Bill and Melinda Gates Foundation, USAID, PATH, John Snow Inc, World Health
Organization, Management Sciences for Health, Save the Children, FHI-360 and MDG
Health Alliance.
8