UGANDA 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
INTEGRATED GLOBAL ACTION PLAN FOR PNEUMONIA AND DIARRHOEA
April, 2013
THE CHALLENGE
In 2011, 131,000 children in Uganda did not reach their 5th birthdays putting Uganda on
the list of countries with the highest burdens of child mortality.
Pneumonia is the single
largest cause of death among children in Uganda, causing an estimated 22,000 (18%)
under 5 deaths and around 2 million episodes of sickness every year at an enormous cost
Causes of under-five mortality in
to children and families.2 While it is true that
the majority of child pneumonia deaths
Uganda
AIDS
can be prevented with cost effective vaccines
and low cost antibiotics, Uganda has low
Diarrhea
7%
rates of basic immunization coverage
and has not yet introduced the pneumococcal vaccine
10%
Meningitis
Pneumoniare treated with antibiotics.
and just 47% of all children with suspected pneumonia
2%
In
a
18%sanitation (34%) and high rate of
addition, Uganda’s low rate of access to improved
Birth
asphyxia
Malaria
undernutrition (38% children are stunted)
are both factors
contributing to the large
8%
13%
3
number of child pneumoniaCongenital
deaths.
With concerted and coordinated action on these
Injuries
anomalies
fronts most of the 22,000 child
be averted taking Uganda one
1% pneumonia deaths could 5%
big step closer to achievingPrematurit
Millennium Development Goal 4 (MDG4).4
y
10%
1
Neonatal
sepsis
5%
Other
21%
The Pneumonia and Diarrhea Working Group is chaired by UNICEF and the Clinton Health Access Initiative and
supports 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, the recommendations of the UN Commission on Life Saving
Commodities for Women and Children and the Integrated Global Action Plan for Pneumonia and Diarrhoea,
released by WHO/UNICEF in April 2013, and are in support of the United Nations Secretary-General’s, Every
Woman, Every Child movement
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. Uganda: The 2012
Report.
THE OPPORTUNITY
To accelerate progress to MDG4 in the three years remaining to 2015, the Government
of Uganda is driving progress on both the prevention and treatment sides of the
pneumonia challenge.
The Government plans to introduce the pneumococcal vaccine in
stages by 2015 and the Ministry of Health has developed plans to scale up pneumonia
and diarrhea treatment in partnership with the Clinton Health Access Initiative and other
stakeholders.
These plans include the actions needed to achieve universal coverage of
essential medicines to treat pneumonia and diarrhea in the context of expanding
integrated Community Case Management – an approach that trains and equips public
sector health workers to manage the leading killers of children under 5, typically
pneumonia, diarrhea and in relevant countries malaria.
The plans underscore the
importance of early diagnosis of pneumonia, acknowledging that many child deaths are the
result of a failure to seek treatment in time, and aim to increase access to the
antibiotic amoxicillin, preferably in dispersible tablet form, from 50% to 80% by 2015.
In addition to improving the way the public health sector responds to sick children,
stakeholders have highlighted the need to improve the way private health providers
respond to children with suspected pneumonia as the vast majority (65%) of caregivers
seek treatment in the private sector in Uganda.
Importantly, stakeholders also argue for a new approach to managing children who present
with symptoms of pneumonia and malaria to correct what it describes as “treatment bias
away from pneumonia”.
Citing cases where 45% of children who presented with
symptoms of both malaria and pneumonia were sent away with malaria medicines alone
and where 37% of fatal pneumonia cases were misdiagnosed as malaria, there is a call for
2
greater integration in the diagnosis and treatment of pneumonia and malaria particularly
in the private sector where most children seek care and where diagnostic tools are rarely
available and amoxicillin cannot be legally sold over-the-counter.5
Key elements of the scale up plans include:
PRIORITY ACTIONS TO SCALE UP ACCESS TO PNEUMONIA TREATMENT IN UGANDA
1) Educating Families &
2) Supporting Private
3) Supporting Public Sector
Caregivers
Sector Provision
Provision
-Teach families and
-Train private health
-Progressively expand
caregivers about pneumonia,
providers to better manage
integrated Community Case
the seriousness of the
childhood pneumonia (65%
Management (iCCM) to all
infection, and how to
of those seeking care outside
districts, prioritizing those
recognize the danger signs
the home use the private
with the greatest need
(fast breathing and chest
sector first)
-Train and equip Village
“indrawing”)
-Increase the supply of
Health Teams (VHTs) to
quality, affordable amoxicillin
diagnose and treat
care outside the home from
dispersible tablets
pneumonia with amoxicillin
qualified health providers
-Increase the relative
dispersible tablets (VHTs
quickly (30% of children
affordability of amoxicillin
trained in less than ¼ of
with pneumonia are treated
dispersible tablets compared
districts)
at home)
to other antibiotics (e.g.
-Improve forecasting,
-Educate families about
cotrimoxazole) and common
procurement and supply of
amoxicillin dispersible
pneumonia treatments
amoxicillin dispersible tablets
tablets, how they work and
-Expand the Sustainable
in the public sector
the importance of
Drug Sellers Initiative
-Train and equip hospital
completing a full course of
enabling more private
and facility staff to treat
treatment
providers to sell amoxicillin
severe pneumonia with
-Introduce behavior change
dispersible tablets
recommended antibiotics and
-Encourage families to seek
campaigns targeted to the
oxygen where necessary
most vulnerable families and
-Establish 14 Regional
to the health providers who
Referral Pneumonia Centers
treat the majority of
to diagnose and treat severe
pneumonia cases
pneumonia with pulse
-Support programs that
oximeters and access to
empower mothers to
oxygen concentrators
improve the health of their
children
5
Uganda, Essential Childhood Medicines Scale-Up Strategy, Diarrhea and Pneumonia, 2012-2015
3
4) Diagnostics
5) Local Manufacturing
6) Regulatory & Policy
-Increase use of easy-to-use
-Work with pharmaceutical
Changes
and effective respiratory
companies to increase local
-Disseminate pneumonia
rate timers in public and
manufacturing,
policies, standards and
private sectors
marketing and distribution
treatment guidelines
-Increase use of pulse
of quality, affordable
throughout the public and
oximetry in facilities and
amoxicillin dispersible tablets
private health sectors
access to oxygen
(currently only 1 registered
-List amoxicillin dispersible
-Train and equip public and
dispersible tablet but many
tablets on all Essential
private health outlets to
syrups)
Medicines and Drug Lists
administer Rapid Diagnostic
-Offer fast track
-Better monitor the quality
Tests (RDTs) for malaria
registration for locally
of antibiotics being used to
(currently tests are only
manufactured amoxicillin
treat child pneumonia
available in fewer than 30%
dispersible tablets that
-Remove regulatory barriers
of health facilities)
meet quality and price
to local pharmaceutical
-Train and equip health
targets
production of amoxicillin
outlets to dispense
-Offer “umbrella brand
dispersible tablets
amoxicillin dispersible tablets
endorsement” for locally
-Improve coordination across
to children whose RDT
manufactured amoxicillin
government programs and
results are negative and
dispersible tablets that
processes relating to child
who exhibit symptoms of
meet quality and price
survival (e.g. vaccines,
pneumonia
targets
community case
- Work with manufacturers
management, HIV/AIDS,
to distribute dispersible
malaria, nutrition, newborn
amoxicillin tablets to rural
etc)
areas
-Integrate the VHT supply
chain (run entirely by
NGOs) and the National
Medical Stores Supply Chain
BEST PRACTICE PNEUMONIA DEMONSTRATION PROJECTS
To support the introduction of the pneumococcal vaccine and the implementation of the
Government’s
essential
medicines
scale
up
plans,
we
propose
Pneumonia Demonstration Projects be considered in Uganda.
that
Best
Practice
By combining the most
effective pneumonia prevention, diagnosis and treatment interventions in geographic areas
with the highest concentrations of child deaths, the Projects will seek to demonstrate
how to accelerate child mortality reductions and achieve efficiencies in the delivery of
healthcare to children through better coordination across child survival programs in both
4
the public and private sectors.6
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 and to reduce newborn infections).
Target sites 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
introduction
or
expansion
of
integrated Community Case Management.
The
Government may prefer a mix of sites to test
different approaches and evaluate outcomes.
Of
Uganda’s ten health sub-regions, the Western,
South West, Eastern and East Central sub-regions
have
the
deaths.
highest
concentrations
of
under
5
Of particular concern are the relatively
large numbers of children in these regions who
reported symptoms of pneumonia in the 2011
Demographic and Health Survey who did not
receive antibiotics.
with
symptoms
of
More than 60% of children
pneumonia
in
these
regions were not treated with antibiotics.
four
7
For maximum impact it is important that the Projects: (a) be at significant scale, (b)
better coordinate the delivery of vaccines with the community case management of
pneumonia, diarrhea and malaria, (c) stimulate the development of local manufacturing of
amoxicillin dispersible tablets, (d) target the providers of pneumonia treatment who
treat the majority of children, (e) test best practice approaches to the diagnosis of
pneumonia in a way that improves treatment outcomes and reduces healthcare costs
(e.g. by reducing wastage of malaria medicines), (f) test innovations in pneumonia
prevention, diagnosis and treatment, including respiratory rate counters, pulse oximeters,
oxygen concentrators and user-friendly packaging of amoxicillin dispersible tablets, and g)
rigorously and independently monitor and evaluate impact.
6
Phyllis Awor and colleagues have recommended that private sector drugshops in Uganda be included in
integrated Community Case Management following survey findings that showed that 53% of sick children sought
treatment in private drugshops where the care was largely inappropriate. See Private Sector Drugshops in
Integrated Community Case Management of Malaria, Pneumonia and Diarrhea in Children in Uganda, American
Journal of Tropical Medicine and Hygiene, 2012
7
Uganda Demographic and Health Survey, 2011
5
Specifically the Projects in Uganda 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 including with the
measles, Hib and pneumococcal vaccines

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, soap, insecticide-treated bed nets
etc)

Maximize uptake of prevention commodities with proven strategies (e.g. free
trials, time payments, rights to return and rights to stop payments) 8
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 pneumonia with amoxicillin dispersible tablets

Provide easy-to-use respiratory rate counters to health providers

Train facility based staff to effectively treat children with pneumonia including
better access to pulse oximetry and oxygen

8
Introduce community-based monitoring of public and private healthcare providers
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
6
to improve service utilization and health outcomes for children9
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 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 the prevention, diagnosis and
treatment sides – working together for collective impact.10
To maximize collective
impact, partners for the Demonstration 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.
These Projects can build off the work of several partnerships already active in Uganda.
Other potential partners include:
Absolute Return for Kids11, Abt Associates, bilateral development agencies (e.g. NORAD,
CIDA, DfID, DANIDA, AusAID), Bill and Melinda Gates Foundation, BRAC Uganda,
9
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
10
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
11
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
Children’s Investment Fund Foundation, Clinton Health Access Initiative, FHI-360, GAVI,
GFATM, Infectious Diseases Institute, International Rescue Committee, International
Vaccine Access Center, John Snow International, Living Goods, Malaria Consortium,
Malaria No More, Management Sciences for Health, Marie Stopes, MCHIP, Program for
Accessible Health, Communication and Education , Uganda Health Marketing Group, Uganda
Pediatric Association, Uganda Medical Association, Uganda pharmaceutical companies (e.g.
Abacus, Astra, Gittoes, Kampala Pharmaceutical, Medipharm Industries, Nutriset, Phillips,
Shelys,
Surgipharm,
Unilever,
Zenufa
Laboratories),
PSI,
UNICEF,
United
Nations
Foundation, WHO, World Vision International and the 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