Development and Implementation of a National Programme for the Management of Severe and Very Severe Pneumonia in Children in Malawi

Mwansambo C (2009) Development and Implementation of a National Programme for the Management of Severe and Very Severe Pneumonia in Children in Malawi. PLoS Med 6(11): e1000137. doi:10.1371/journal.pmed.1000137 Development and Implementation of a National Programme for the Management of Severe and Very Severe Pneumonia in Children in Malawi Penelope Marjorie Enarson 0 1 Robert Gie 0 1 Donald A. Enarson 0 1 Charles Mwansambo 0 1 0 Abbreviations: CLHP, Child Lung Health Programme; IMCI, Integrated Management of Childhood Illness; SCM , standard case management 1 1 International Union Against Tuberculosis and Lung Disease, Child Lung Health Division , Paris , France , 2 Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University , Tygerberg , South Africa , 3 Kamuzu Central Hospital, Department of Paediatrics , Lilongwe , Malawi - The reduction of child mortality by twothirds from its 1990 level by 2015the fourth United Nations Millennium Development Goalis a major challenge. Pneumonia accounts for much ($20%) of this mortality in poor countries, but standard case management (SCM) of pneumonia [1] has the potential to reduce overall child mortality. A recent meta-analysis estimated that SCM of pneumonia could reduce overall mortality in neonates, infants under 1 y old, and children aged 04 y, respectively, by 27%, 20%, and 24%, and pneumonia-specific mortality by 42%, 36%, and 36% in the same age groups [2]. However, even proven intervention strategies cannot function without an effective delivery strategy [3]. For, example, although the World Health Organization (WHO)/United Nations Childrens Fund has developed an Integrated Management of Childhood Illness (IMCI) strategy to reduce child mortality, of the 100+ low- and middle-income countries that introduced IMCI in the 1990s, only 48% had scaled up coverage by the end of 2002. Weak health systems were the main cause of this failure with the poorest countries doing worst [3]. We describe here the development and scaling-up of a country-wide delivery strategy of SCM for pneumonia in children in Malawi, a country where more than 200 children per thousand die before they are 5 y old. The International Union Against Tuberculosis and Lung Disease (The Union) The Health in Action section is a forum for individuals or organizations to highlight their innovative approaches to a particular health problem. previously pioneered an effective delivery model for antituberculosis services [4] for patients in poor countries. The approach used in this framework, which is one of the most cost-effective health interventions [5] devised so far, was incorporated into the WHO Stop TB Strategy and, by 2005, it had been successfully introduced into 190 countries [6]. Its principles include political commitment, standardized diagnosis and treatment, training, logistics, recording and reporting, supervision, and evaluation of services. The Union has adapted this model to improve the management of severe and very severe pneumonia in children admitted to first-level (district) hospitals, institutions that are accessible to the whole population but where care is often deficient [79]. The framework allows accurate accounting of services, materials, and training, facilitates the calculation of outcome per unit of cost, and permits the management of supplies to avoid disruption of essential materials. The model focuses on strengthening district hospitals and their associated health centresthe basic management unit. Thus, it should facilitate the management of pneumonia in institutions that are peripheral enough to promote access but central enough to facilitate monitoring and evaluation. The core elements of this approach for the delivery of SCM for pneumonia are: N Political commitment of the government for countrywide implementation within existing health systems and the support of a donor partner to assist until the programme is self-sustaining. This element implies that there is/are: # an existing structure for deliv ering the services; N Training of clinical staff in SCM. N Logistics to purchase and distribute uninterrupted supplies of standardized drugs. N Recording and reporting of clinical outcomes of pneumonia. Implementation of a Child Lung Health Programme In 1999 the Government of Malawi asked The Union to assist it in the development and implementation of a Child Lung Health Summary Points N More than 20% of child mortality in poor countries is due to pneumonia. N Standard case management of pneumonia has the potential to reduce overall child mortality, provided it can be delivered effectively. N The government of Malawi recently introduced a national programme for the delivery of standard case management for pneumonia in children in Malawi with the help of technical and donor partners. N This Health in Action article describes the development, scale-up, and achievements of this national programme, which is based on a successful antituberculosis service delivery model, and discusses the challenges facing the implementation of this adapted service delivery model. the following criteria: presence of a functioning ARI and/or IMCI programme; commitment of the District Health Officer to the CLHP; availability of a designated health worker who, in addition to normal activities, assumed responsibility for implementation; and a catchment area of approximately 100,000 population. A plan for regular monitoring was then developed. Training Health Management Personnel The programme manager and staff at each implementation site participated in intensive training to enhance their management skills and the computer skills needed to efficiently manage information. Training Inpatient and Outpatient Health Care Workers in Case Management A CLHP training manual and modules were adapted to local conditions and used as a standard operating and reference manual. The training curriculum for health care workers, although focused on SCM of childhood lung diseases (pneumonia, tuberculosis, asthma, and HIV-related lung disease), also included case management of other major childhood illnesses (malnutrition, diarrhoea, malaria, anaemia, and meningitis) because children frequently presented with comorbid conditions. Annual training courses focused on theoretical and practical case management using local paediatric facilities and initially relied on an international course faculty. Local faculty gradually took on more responsibility for these courses. Oneday follow-up training sessions took place 46 wk after the annual course plus ongoing in-service training. Monitoring Progress Information routinely collected to provide patient care formed the core of the CLHP monitoring activities. Information Programme (CLHP) to manage children under 5 y old hospitalized with severe/very severe pneumonia. The government identified the following problems: (1) inadequate health-worker skills in district hospitals; (2) inade (...truncated)