NIGERIA BEST PRACTICE PNEUMONIA DEMONSTRATION PROJECTS
DRAFT PROPOSAL OF THE PNEUMONIA AND DIARRHEA WORKING GROUP1
in support of
THE SAVING ONE MILLION LIVES INITATIVE
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, 756,000 children in Nigeria did not reach their 5th birthdays putting Nigeria at #2 on
the list
of
countries with
the highest
burdens of
child mortality.
Pneumonia caused
approximately 130,000 (17%) of these deaths and an estimated 13 million episodes of sickness
every year at an enormous cost to children and families2. While it is true that the majority of
of under-five
in Nigeria
child pneumonia deaths can beCauses
prevented
with costmortality
effective
vaccines and low cost antibiotics,
Meningitis
the majority of children in NigeriaMeasles
do not receive
either.
3%
causes of pneumonia – the
HIV/AIDS1%
Hib
and pneumococcal
4%
The vaccines that prevent the leading
vaccines – are not yet available to all Nigerian
children but are in the process of being introduced in select states, and currently just 23% of all
Pneumonia
Other
Injuries
children with suspected pneumonia
are treated 17%
with antibiotics.
3%
15%
In addition, Nigeria’s relatively
low rates of exclusive breastfeeding (13%), access Diarrhea
to improved sanitation (31%) and high rate of
12%
undernutrition (41%
of sepsis
children are stunted) are all factors contributing to the large number of
Neonatal
6% 3
child pneumonia deaths.
With concerted and coordinated action on these fronts most of the
Congenital
130,000 child pneumonia anomalies
deaths could be
1%
Prematurity
Millennium Development Goal 4 (MDG4).4
Birth asphyxia
10%
8%
1
Malaria
averted
20% taking Nigeria one big step closer to achieving
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 Scale-Up 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 by 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
Source: Countdown to 2015: Maternal, Newborn and Child Survival. Nigeria:
The 2012 Report.
THE OPPORTUNITY
To accelerate progress to MDG4 in the three years remaining to 2015, the Government of
Nigeria is driving progress on both the prevention and treatment sides of the pneumonia
challenge.
The Hib vaccine (one of the five vaccines included in the Pentavalent vaccine) is in
the process of being introduced in select Nigeria States and the pneumococcal vaccine is scheduled
for introduction in 2013 in three phases. 5
On the pneumonia treatment side, the Ministry of
Health’s National Primary Health Care Development Agency (NPHCDA) has prepared and
endorsed an Essential Medicines Scale-Up Plan which outlines the actions needed to dramatically
increase the numbers of children with suspected pneumonia who are treated with antibiotics to
80% by 2015, in the context of expanding integrated Community Case Management.
Key elements of the Plan include:
PRIORITY ACTIONS TO SCALE-UP ACCESS TO PNEUMONIA TREATMENT IN NIGERIA
1) Educating Families &
2) Supporting Private Sector
3) Supporting Public Sector
Caregivers
Provision
Provision
-Teach families and caregivers
-Train private health providers
-Train and equip Community
about pneumonia, the
particularly Proprietary
Health Extension Workers
seriousness of the infection,
Patent Medicine Vendors
(CHEWs) to diagnose and
5
Phase 1 vaccine introduction in Kebbi, Kaduna, Bauchi, Taraba, FCT, Kwara, Kogi, Edo, Ekiti, Rivers,
Lagos, Anambra and Enugu; phase 2 in Kano, Jigawa, Gombe, Adamawa, Plateau, Benue, Osun, Ondo, Cross
River, Ebony, Imo, Akwa-Ibom, Ekiti and Lagos and phase 3 in remaining states.
2
and how to recognize the
(PPMVs) to better manage
treat pneumonia with
danger signs (fast breathing
childhood pneumonia (40% of
amoxicillin dispersible tablets
and chest “indrawing”)
sick children are treated in
-Improve forecasting,
the private sector)
procurement and distribution
care outside the home from
-Increase the supply and
of quality, affordable amoxicillin
qualified health providers
affordability of amoxicillin
dispersible tablets in the public
quickly (currently 30% of
dispersible tablets
sector (75% of Public Health
children with pneumonia are
-Increase the relative
Centers report antibiotic
treated at home)
affordability of amoxicillin
stockouts)
-Educate families about
dispersible tablets compared
-Train and equip hospital and
amoxicillin dispersible tablets,
to other antibiotics (e.g.
facility staff to treat severe
how they work and the
cotrimoxazole) and common
pneumonia with recommended
importance of completing a
pneumonia treatments
antibiotics and oxygen where
-Encourage families to seek
full course of treatment
necessary
-Introduce behavior change
-Upgrade hospitals and facilities
campaigns targeted to the
to treat severe pneumonia and
most vulnerable families and
increase access to pulse
to the health providers who
oximeters and oxygen
treat the majority of
concentrators
pneumonia cases
-Support programs that
empower mothers to improve
the health of their children
4) Diagnostics
5) Local Manufacturing
6) Regulatory & Policy Changes
-Increase use of easy-to-use,
-Work with pharmaceutical
-Allow CHEWs to dispense
effective respiratory rate
companies to increase local
amoxicillin dispersible tablets
counters in public and private
manufacturing, marketing and
-Disseminate pneumonia
sectors
distribution of quality,
policies, standards and
-Increase use of pulse
affordable amoxicillin
treatment guidelines
oximetry in facilities and
dispersible tablets
throughout the public and
access to oxygen
-Offer fast track registration
private sectors
-Train and equip public and
for locally manufactured
-List amoxicillin dispersible
private health outlets to
amoxicillin dispersible tablets
tablets on all Essential
administer Rapid Diagnostic
that meet quality and price
Medicines and Drug Lists
Tests (RDTs) for malaria
targets
-Better monitor the quality of
(currently tests are only
-Offer “umbrella brand
antibiotics being used to treat
available in fewer than 30%
endorsement” for locally
child pneumonia
of health facilities)
manufactured amoxicillin
-Explore responsible strategies
-Train and equip health
dispersible tablets that meet
for community-based
outlets to dispense amoxicillin
quality and price targets
distribution of
dispersible tablets to children
-Work with manufacturers to
dispersible tablets by PPMVs
amoxicillin
3
whose RDT results are
distribute dispersible
-Remove regulatory barriers to
negative and who exhibit
amoxicillin tablets to rural
local pharmaceutical production
symptoms of pneumonia
areas
of amoxicillin
dispersible tablets
-Improve coordination across
Government programs and
processes relating to child
survival (e.g. vaccines,
community case management,
HIV/AIDS, malaria, nutrition,
newborn etc)
Further, the Nigerian Minister of State for Health, Dr Muhammad Pate, has brought new
vaccine delivery together with improved access to essential medicines for the treatment of
pneumonia, diarrhea and malaria in the Saving One Million Lives Initiative, which was launched in
Nigeria in October 2012.
The Initiative sets a target of saving the lives of one million women
and children by 2015 and lays out specific plans to reach that goal.
As the second leading cause
of death for children under 5 in Nigeria, pneumonia is a critical plank of the plan.
Saving One
Million Lives is also an opportunity for Nigeria to implement the recommendations of the United
Nations Commission on Life-Saving Commodities for Women and Children that relate to
pneumonia, specifically to increase access to the antibiotic amoxicillin in dispersible tablet form as
the first-line treatment for children with suspected pneumonia and also to increase access to
ORS, zinc and other commodities (e.g. chlorhexidine to reduce newborn infection).
The
President of Nigeria co-chaired the Commission and has signaled the Government’s intention to
introduce amoxicillin dispersible tablets as the preferred treatment for childhood pneumonia.
There is now an opportunity to combine new vaccine introduction with access to essential
medicines for pneumonia, diarrhea and malaria across several States to accelerate achievement of
the goals of Saving One Million Lives.
BEST
PRACTICE
PNEUMONIA
DEMONSTRATION PROJECTS
To
support
the
introduction
of
new
vaccines and the implementation of the
Government’s Essential Medicines Scale-Up
Plan in the context of Saving One Million
Lives,
we
propose
that
Best
Practice
Demonstration Projects be considered in
Nigeria.
By combining the most effective
pneumonia
prevention,
diagnosis
and
treatment interventions in the geographic
4
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.
The Projects are also an
opportunity to strengthen integrated Community Case Management of pneumonia, malaria and
diarrhea in Nigeria and incorporate other high impact interventions to reduce newborn mortality
(e.g. chlorhexidine) and malnutrition (e.g. expansion of Community Management of Acute
Malnutrition).
Target States could include those that will introduce the pneumococcal vaccine first; those that
have the highest concentrations of under 5 deaths, and/or those targeted by the Government
for introduction or expansion of integrated Community Case Management.
The States that will
introduce the new vaccines first include Kaduna and Kebbi (North West Zone), Bauchi and
Taraba (North East Zone), Kwara and Kogi (North Central), Ekiti (South West), Edo (South
South) and Anambra (South East).
Of these States, child deaths are highest in Kaduna,
Bauchi, Kebbi, Taraba and Anambra and a focus on these States would potentially have the
biggest impact on child survival.
The Government may prefer a mix of sites to test different
approaches and evaluate the outcomes.
For maximum impact, it is important that the Projects: (a) be at significant scale (i.e. across
several States), (b) better coordinate the delivery of vaccines with integrated 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 provide care for the majority of children, (e) test best practice approaches to the
differential diagnosis of malaria and pneumonia and measure impact on treatment outcomes and
healthcare costs (e.g. by reducing wastage of malaria medicines), (f) test innovations in
pneumonia prevention, diagnosis and treatment (e.g. respiratory rate counters, pulse oximeters,
oxygen concentrators and user-friendly packaging of amoxicillin dispersible tablets) and g)
rigorously and independently monitor and measure impact.
Specifically the Projects in Nigeria 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

Increase understanding of the difference between the symptoms of malaria and pneumonia

Explain to families the importance of having children immunized with the measles,
pentavalent 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
5
services in the public sector and, where appropriate, incentives (e.g. vouchers, conditional
cash transfers) for seeking care from private providers
2. Prevention

Increase coverage of the measles, pentavalent 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 breastfeeding, 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, insecticide treated bed nets, soap etc)

Maximize uptake of prevention commodities with proven strategies (e.g. free trials, time
payments, rights to return and rights to stop payments) 6
3. Treatment

Introduce quality, affordable amoxicillin dispersible tablets, locally manufactured where
possible

Train and equip CHEWs and PPMVs to better manage childhood pneumonia with
amoxicillin dispersible tablets

Provide easy-to-use, effective respiratory rate counters to health providers

Train public and private 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 and community-based services to treat acute
malnutrition

Introduce community-based monitoring of public and private healthcare providers to
improve service utilization and health outcomes for children 7
4. Malaria

Improve differential diagnosis of malaria and pneumonia by increasing coverage of Rapid
Diagnostic Tests and training health workers in their proper use
6
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
7
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

Train and equip testers to administer amoxicillin dispersible tablets when the results of
RDTs are communicated so that children who test negative can be treated for suspected
bacterial pneumonia on the spot
5. 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 pneumonia (e.g. rapid acting bronchodilators and oxygen concentrators) and
adherence with antibiotic treatment (e.g. user-friendly packaging of amoxicillin and simple,
clear instructions for caregivers)
6. Impact

Rigorously and independently monitor and measure impact on treatment outcomes and
healthcare costs (including the impact on malaria medicines) 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 highest burden States and mobilize the
right set of public and private partners to drive uptake on both the prevention, diagnosis and
treatment sides – working together for collective impact.8
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 with the introduction and expansion of integrated Community Case
Management.
In addition to the partners sponsoring this proposal, other potential partners include:
Absolute
Return for Kids (ARK) , BBC Media Action, bilateral development agencies (e.g. NORAD, CIDA,
9
DfID), Bill and Melinda Gates Foundation, Children’s Investment Fund Foundation, Clinton Health
Access Initiative, Federation of Moslem Women’s Associations of Nigeria, GAVI, Global Fund,
Health Partners International, International Vaccine Access Center, John Snow International,
Malaria Consortium, Malaria No More, Medical Women’s Association of Nigeria, National
8
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.
9
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
Association of Community Pharmacists, National Association of Patent and Proprietary Medicine
Distributors, Nigerian
Interfaith
Action
Association, Nigerian
Medical
Association, Nigerian
Primary Health Center Development Agency, Nigerian Private Sector Health Alliance, Partnership
for Reviving Routine Immunization in Northern Nigeria, Pediatric Association of Nigeria, PATH,
Nigerian
pharmaceutical
companies
(e.g.
CHI,
Emzor,
May
and
Baker),
Pharmaceutical
Manufacturing Group, Save the Children, Sesame Workshop, Society for Family Health, UN
Special Envoy for Malaria, Wellbeing Foundation 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 the MDG Health Alliance
8