Transcript Community Case Management Of Serious, Common, Childhood

Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria
Non-Governmental Organization Teleconference
April 7, 2011
Community Case Management
Of Serious, Common, Childhood Infections in
High Mortality Countries:
Rationale, Experience, and Opportunities
David R. Marsh, MD, MPH
Senior Advisor, Child Survival
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Global Team Leader, Community Case Management
Outline
• Rationale and definition
• Experience
– Programs
– Research
• Opportunities
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Rationale
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Causes of Child Death – 2008*
*Slide courtesy
of S Qazi and
T Cherian,
WHO/CAH
Global
 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
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"Protect, Prevent, Treat" African Regional Workshop on coordinated
approaches to pneumonia and diarrhoea prevention and control
Uneven coverage patterns across interventions*
Coverage levels for countdown interventions and approaches, 68 priority countries
Hib3 immunization
DPT3 immunization
Measles immunization
Vitamin A supplementation (2
Improved drinking water
Complementary feeding (6-9
Skilled attendant at delivery
4+ antenatal care visits
Careseeking for pneumonia
Improved sanitation facilities
Early initiation of breastfeeding
Malaria treatment
Diarrhoea treatment
Antibiotics for pneumonia
Exclusive breastfeeding
Children sleeping under ITNs
IPTp for malaria
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Source: WHO CAH department; WHO-UNICEF
immunization coverage estimates
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 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
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79
80
78
69
62
53
49
48
43
43
40
38
32
28
7
7
 Coverage with other
interventions is low
and in some instances
declining
20
40
60
%
"Protect, Prevent, Treat" African Regional Workshop on coordinated
approaches to pneumonia and diarrhoea prevention and control
80
100
*Slide courtesy
of S Qazi and
T Cherian,
WHO/CAH
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 evidencebased 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
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HOME
Drugs & Equipment
Spoons, timer,
mixing containers,
(Nicaragua)
counseling cards,
raincoat, forms
Antibiotic, zinc,
ORS, antipyretic
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Counting respirations.
Encounter (Nicaragua)
Treatment
Register
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Supervision
Health Worker with her
Supervisor and her
(Nicaragua)
Supervisor’s Supervisor
Supervision
Checklist
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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
Provider Retention
(7/05-8/06)
% 100
100
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
0
Before CCM
After CCM*
38/40
7/14
CCM Worker* Facility Staff
*SC trained 45 and certified 40 CCM providers
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Use of Case Management (7/05-8/06)
# 5000
• 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
4000
3000
2000
1000
0
Facility Staff CCM Worker
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Quality of CCM Services
% 100
80
60
40
20
0
Case
Scenarios (3)
Register
No Stockout
Reporting
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Treatment Seeking for Cough and Difficult
Breathing (1997-2006)
Clinic-based
treatment of
pneumonia
and malaria.
90
80
%
CCM of
pneumonia
and malaria.
*
70
60
50
40
30
20
10
17%
58%
84%
0
1997
2001
* = 200,000 untreated cases of
childhood pneumonia, malaria, and
diarrhea every year
2006
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Treatment Seeking for Cough and Difficult
Breathing (1997-2006)
Clinic-based
treatment of
pneumonia
and malaria.
90
80
%
CCM of
pneumonia
and malaria.
*
70
CCM
60
50
40
30
20
10
17%
58%
84%
0
1997
2001
* = 200,000 untreated cases of
childhood pneumonia, malaria, and
diarrhea every year
2006
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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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Corporate Opportunities to Advance the
Agenda
• 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
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Twa to te la
Photo by Cleis
谢谢 (xièxiè)
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