1 Community Case Management Of Serious, Common, Childhood Infections in High Mortality Countries: Rationale, Experience, and Opportunities Global Business.

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Community Case ManagementOf Serious, Common, Childhood Infections in

High Mortality Countries: Rationale, Experience, and Opportunities

Global Business Coalition on HIV/AIDS, Tuberculosis and MalariaNon-Governmental Organization TeleconferenceApril 7, 2011

David R. Marsh, MD, MPHSenior Advisor, Child Survival

Global Team Leader, Community Case Management

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Outline

• Rationale and definition

• Experience– Programs– Research

• Opportunities

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Rationale

"Protect, Prevent, Treat" African Regional Workshop on coordinated approaches to pneumonia and diarrhoea prevention and control4 |

Causes of Child Death – 2008*Causes of Child Death – 2008*

Globally, pneumonia, diarrhea, and malaria account for 41% of 8,000,000 deaths (3.3 million) annually.

In Africa they account for 53% of the 4,200,000 deaths in (2.2 million) annually.

WHO CHERG estimates, Black et al Lancet 2010

Global

*Slide courtesy of S Qazi and T Cherian, WHO/CAH

"Protect, Prevent, Treat" African Regional Workshop on coordinated approaches to pneumonia and diarrhoea prevention and control5 |

Source: WHO CAH department; WHO-UNICEF immunization coverage estimates

Uneven coverage patterns across interventions* Coverage levels for countdown interventions and approaches, 68 priority countries

Uneven coverage patterns across interventions* Coverage levels for countdown interventions and approaches, 68 priority countries

Though the global average immunization coverage is high, coverage with Hib vaccine is low and pneumo and rotavirus vaccines have to be introduced and scaled up

Coverage with other interventions is low and in some instances declining

*Slide courtesy of S Qazi and T Cherian, WHO/CAH

%

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Irrawaddy Delta “Highway” (Myanmar)

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Socio-economic Impact of Childhood Infection

• Infection predisposes to malnutrition, which increases risk of more infection, more malnutrition...

• Children miss learning (pre-school or school): short-term effects on the child, long-term effects on society– Malnutrition further compromises learning

• Caregivers miss work, reducing earnings and productivity

• Families spend resources on treatment and transport, reducing ability to purchase other goods and services

• CCM (1) saves time, money and human capital, (2) halts the progression of disease and (3) interrupts the infection-malnutrition cycle

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Definition

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CCM is a strategy in which…

• A health system trains, supplies and supervises front-line workers in communities without access to health facilities to treat children using evidence-based protocols for common, serious infections:– Mainly diarrhea, pneumonia, and malaria – And sometimes dysentery, newborn sepsis

and acute malnutrition.

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Sick Child Recording Form

ASK

LOOK

DECIDE

ACT: REFER

ACT: TREAT

AT HOME

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Drugs & Equipment (Nicaragua)

Antibiotic, zinc, ORS, antipyretic

Spoons, timer, mixing containers, counseling cards, raincoat, forms

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Encounter (Nicaragua)Counting respirations.

Treatment Register

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Supervision (Nicaragua)

Supervision Checklist

Health Worker with her Supervisor and her Supervisor’s Supervisor

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Programs

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Projects, Programs, and/or Technical Assistance to Governments (22)

• Asia (8): Afghanistan, Bangladesh, China, India, Indonesia, Myanmar, Nepal, Pakistan

• Africa (9): Angola*, Ethiopia, Mali, Malawi, Mozambique, Nigeria, South Sudan, Uganda, Zambia

• Latin America (5): Bolivia*, Dominican Republic, Guatemala, Haiti, Nicaragua

*closed

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Research

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Evaluation of a CCM Demonstration (2005-06) in Liben District, Oromiya

Region, Ethiopia

Total Population: 138,000 (2001)Under five mortality: 161/1000 live births

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Access to Case Management

0

10

20

30

40

50

60

70

80

90

100

Before CCM After CCM*0

10

20

30

40

50

60

70

80

90

100

CCM Worker* Facility Staff

Provider Retention (7/05-8/06)

%

38/40 7/14

*SC trained 45 and certified 40 CCM providers

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0

1000

2000

3000

4000

5000

Facility Staff CCM Worker

• CCM volunteers saw on average 12 cases/month – Feasible

• Minor CCM disease (“cough/cold”): 4% – Not overused

• Severe CCM disease: 2.8% – Early care-seeking

#

Use of Case Management (7/05-8/06)

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0

20

40

60

80

100

CaseScenarios (3)

Register No Stockout Reporting

%

Quality of CCM Services

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0

10

20

30

40

50

60

70

80

90

1997 2001 2006

Treatment Seeking for Cough and Difficult Breathing (1997-2006)

% *

* = 200,000 untreated cases of childhood pneumonia, malaria,

and diarrhea every year

17%

58%

84%

Clinic-based treatment of pneumonia

and malaria.

CCM of pneumonia

and malaria.

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0

10

20

30

40

50

60

70

80

90

1997 2001 2006

Treatment Seeking for Cough and Difficult Breathing (1997-2006)

% *

* = 200,000 untreated cases of childhood pneumonia, malaria,

and diarrhea every year

17%

58%

84%

Clinic-based treatment of pneumonia

and malaria.

CCM of pneumonia

and malaria.

CCM

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Scale (2009-2011)

• Publication: Degefie T, Marsh DR, Gebremariam A et al. Community case management improves use of treatment for childhood diarrhea, malaria and pneumonia in a remote district in Ethiopia’s Oromiya Region, Eth J of Hlth Dev 2009; 23(2):120-126.

• Stakeholder buy-in: Ethiopian Pediatrics Society recommended Health Extension Workers to treat pneumonia (2009)

• Policy change: 2010• National implementation: Broad partnership to roll

out community-based pneumonia treatment in 100s of districts (2010-2011)

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CCM Training in Ethiopia (2/11)

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Current CCM Research

• Effective access in Malawi, Mali, Zambia• Video-based training in South Sudan• Supervision in Malawi and Ethiopia (mHealth)• Teaming CHW and TBA in Zambia • Effect of demand generation in Pakistan• CCM of severe acute malnutrition in Bangladesh • Severe pneumonia in Pakistan• Cost of pneumonia treatment in Pakistan• Costing in Malawi• Global indicator validation in Malawi, Mali

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Opportunities

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Corporate Opportunities to Advance the Agenda

• Save the Children will continue to: – Speak for children dying from controllable diseases

• Develop materials: printed, videotaped• Take on “a killer”

– Leverage a seat “at the table” for multilateral policy and implementation

• Sponsor a policy meeting or participation from abroad– Contribute to global and country research

• Support answering a research question from your “corporate community” of national relevance

– Provide technical assistance to governments to test, introduce and/or scale up CCM

• Provide gift-in-kind for CHW kit• CHWs: “adopt” 100, supervise 500, train 1000• Sponsor a district, province or country

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• Save the Children’s new directions:– Add CCM for neonatal sepsis into child CCM– Test mobile phone applications (“mHealth”)– Develop and test other technologies for

training, supervision, case management– Strengthen facility-based case management– Engage private sector providers

• Motivate private sector• Support testing public-private partnership

Corporate Opportunities to Advance the Agenda

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Twa to te la 谢谢 (xièxiè)

Photo by Cleis