PUBLIC HEALTH REVIEWS

Community case management of pneumonia: at a tipping point?

Prise en charge communautaire des cas de pneumonie : une stratégie sur le point de l'emporter?

Tratamiento comunitario de los casos de neumonía: ¿punto de inflexión?

David R Marsh^I; Kate E Gilroy^II; Renee Van de Weerdt^III; Emmanuel Wansi^IV; Shamim Qazi^{V, 1}

^ISave the Children USA, Amherst, MA, United States of America (USA)
^IIJohns Hopkins University, Baltimore, MD, USA
^IIIUNICEF, New York, NY, USA
^IVBASICS, Arlington, VA, USA
^VChild and Adolescent Health and Development, World Health Organization, Geneva, Switzerland

ABSTRACT

Pneumonia is the leading cause of child mortality globally. Community case management (CCM) of pneumonia by community health workers is a feasible, effective strategy to complement facility-based management for areas that lack access to facilities. We surveyed experts in the 57 African and Asian countries with the highest levels and rates of childhood mortality to assess current policies, implementation and plans regarding CCM of pneumonia. About one-third (20/54) of countries reported policies supporting CCM for pneumonia, and another third (18/54) reported no policy against the strategy. Half (27/54) the countries reported some implementation of CCM for pneumonia, but often on a small scale. A few countries sustain a large-scale programme. Programmes, community health workers and policy parameters varied greatly among implementing countries. About half (12/26)of non-implementing countries are planning to move ahead with the strategy. Momentum is gathering for CCM for pneumonia as a strategy to address the pneumonia treatment gap and help achieve Millennium Development Goal 4. Challenges remain to: (1) introduce this strategy into policy and implement it in high pneumonia burden countries; (2) increase coverage of this strategy in countries currently implementing it; and (3) better define and monitor implementation at the country level.

RÉSUMÉ

La pneumonie est la principale cause de mortalité de l'enfant dans le monde. La prise en charge communautaire (PCC) des cas de pneumonie par des agents de santé appartenant à la communauté est une stratégie faisable et efficace, permettant de compléter la prise en charge en établissement de soins pour les habitants des zones ayant peu accès à ces établissements. Nous avons mené une enquête par l'intermédiaire d'experts dans les 57 pays d'Afrique et d'Asie supportant les plus forts niveaux de mortalité et de taux de mortalité de l'enfant pour évaluer au stade actuel les politiques, la mise en œuvre et les plans concernant la PCC de la pneumonie. Environ un tiers des pays (20/54) ont indiqué qu'ils avaient des politiques appuyant la PCC de la pneumonie et un autre tiers (18/54) n'ont signalé aucune politique à l'encontre de cette stratégie. La moitié des pays (27/54) ont rapporté que la PCC de la pneumonie était mise en œuvre sur leur territoire, mais souvent à petite échelle. Un petit nombre de pays soutiennent des programmes à grande échelle. Les programmes, les agents de santé communautaires et les paramètres politiques varient fortement d'un pays appliquant la PCC à un autre. Environ la moitié (12/26) des pays qui n'appliquent pas la PCC prévoient d'adopter cette stratégie. Le développement de la PCC de la pneumonie, en tant que stratégie pour faire face aux lacunes de la prise en charge classique et aider à la réalisation de l'objectif du millénaire pour le développement n° 4, s'amplifie fortement. Il reste à surmonter les difficultés suivantes : (1) intégrer cette stratégie à la politique sanitaire et la mettre en œuvre dans les pays fortement touchés par la pneumonie ; (2) accroitre la couverture de cette stratégie dans les pays qui l'appliquent actuellement ; et (3) mieux définir et suivre la mise en œuvre au niveau national.

RESUMEN

La neumonía es la causa principal de mortalidad en la niñez a nivel mundial. El tratamiento comunitario de los casos (TCC) de neumonía por los agentes de salud de la comunidad es una estrategia viable y eficaz para complementar el tratamiento basado en los centros sanitarios en las zonas que carecen de acceso a esos centros. Encuestamos a diversos expertos de los 57 países africanos y asiáticos que presentan los niveles y tasas más altos de mortalidad en la niñez a fin de evaluar las políticas, la aplicación y los planes actuales respecto al TCC de la neumonía. Alrededor de una tercera parte (20/54) de los países informaron de políticas de apoyo al TCC, y otra tercera parte (18/54) no informó de ninguna política en relación con esa estrategia. La mitad (27/54) de los países notificaron cierta aplicación del TCC de la neumonía, pero a menudo a pequeña escala. Unos cuantos países mantienen un programa a gran escala. Los programas, los agentes de salud comunitarios y los parámetros normativos diferían mucho entre los países que aplicaban el TCC. Alrededor de la mitad (12/26) de los países que no lo aplican están planteándose adoptar la estrategia. Gana terreno la idea de adoptar el TCC de la neumonía como estrategia para solucionar la brecha terapéutica asociada a esa enfermedad y ayudar a alcanzar el cuarto Objetivo de Desarrollo del Milenio. No obstante, persisten los retos para: (1) incluir esa estrategia en la política y aplicarla en los países con alta carga de neumonía; (2) aumentar la cobertura de esta estrategia en los países que ya la están aplicando; y (3) definir y vigilar mejor su aplicación en los países.

Introduction

Pneumonia is the leading cause of mortality among children under five years of age,¹ despite effective vaccines and nutritional and environmental interventions.^2,3 Most children with signs of pneumonia in developing countries need antibiotics, as they are more likely to have a bacterial etiology.⁴ Expanding the coverage of antibiotic treatment for pneumonia is vital to meet the Millennium Development Goal 4 (MDG 4) of reducing under-five mortality by two-thirds by 2015, compared to 1990 levels.^5,6 However, many children with pneumonia do not receive timely, appropriate treatment at health facilities,⁷ especially children from poorer families.⁸ Community case management (CCM) of pneumonia,⁹ complementing facility-based management, is a strategy to deliver antibiotics outside health facilities where access to treatment is poor.

CCM of pneumonia requires training community health workers (CHWs) to use algorithms developed in the 1980s¹⁰ to assess danger signs in children with a cough, count respiratory rates, and look for chest in-drawing to classify respiratory illness. CHWs recommend and dispense oral antibiotics for cases classified as simple pneumonia, usually in children 2–59 months of age, and refer to health facilities young infants or children with danger signs or chest in-drawing.

CHWs can effectively manage respiratory illness and prescribe antibiotics appropriately,^11–14 with few exceptions.^15,16 A meta-analysis of nine studies found that CCM of pneumonia reduced overall mortality in children 0–4 years by 24% (95% confidence interval, CI: 14–33) and pneumonia-specific mortality in children 0–4 years by 36% (95% CI: 20–49).¹⁷ In 2002, WHO convened experts to review the evidence and field experience of CCM of pneumonia. Their consensus statement called for the national health authorities, WHO, the United Nations Children's Fund (UNICEF) and nongovernmental organizations (NGOs) to support implementation of CCM of pneumonia.¹⁸ A 2005 joint policy recommendation from WHO and UNICEF also recommended that "community-level treatment [of pneumonia] be carried out by well-trained and supervised CHWs".¹⁹

The global health community has renewed appeals for more action to prevent and treat child pneumonia to reach the MDG 4.^3,5,20 Pneumonia case management with antibiotics remains a central control strategy, both through facilities and in the community.³ Here, we review the policies, implementation and plans for CCM of pneumonia in countries with the highest levels of child mortality.

Methods

The study examined CCM of pneumonia among the 57 Asian and African countries included in the 60 countries that were the focus of the first Countdown to 2015²¹ and accounted for 94% of global mortality among children less than five years of age in 2004; Latin American countries (Brazil, Haiti and Mexico) were excluded from the analysis. We defined CCM of pneumonia as oral antibiotics for simple pneumonia in a child 2–59 months of age, administered by a health worker in the community, as defined by the respondent.

Data sources

We drafted, pilot-tested and refined a self-administered questionnaire regarding countries' CCM of pneumonia policies, implementation and plans. Questionnaires were distributed electronically in June 2007 from UNICEF and WHO headquarters and regional offices to WHO and UNICEF in-country Integrated Management of Childhood Illness (IMCI) experts, requesting that they and Ministry of Health counterparts jointly complete the questionnaire. We tracked responses to maximize return and clarified inconsistencies or omissions through follow-on e-mail requests, phone calls and/or face-to-face encounters. Representatives from non-responding countries received four requests.

Respondents were asked about their countries' community IMCI (C-IMCI) policies and components, policies and implementation regarding CHWs dispensing oral antibiotics for pneumonia, other treatments for childhood illnesses provided in the community, and future plans for CCM of pneumonia. Countries currently implementing CCM of pneumonia were also asked about: lead institution(s); start-up year; CHW characteristics; programme characteristics; and programme scale and scope.

In November 2007, we directed a brief, follow-up questionnaire to WHO and UNICEF in-country experts in those countries reporting implementation of, and/or supportive policy for, CCM of pneumonia, to further characterize their situations.

Data analysis

Data were entered, cleaned and analysed using Excel (Microsoft, Seattle, WA, United States of America). We received six first-round and four second-round duplicate questionnaires from different sources in the same countries. All had some discrepancies, for which we contacted in-country child health experts not among the original respondents for clarification.

The country was the principle unit of analysis; we calculated proportions describing policy, implementation and plans for the total sample and for the subsample of countries with CCM of pneumonia. We stratified countries geographically into continental Africa and Asia.²² For description of CHWs, the CHW cadre was the unit of analysis because seven countries reported two types of CHW.

We further prioritized high-mortality countries into those 35 countries with under-five mortality rates greater than 125 or with over 100 000 deaths annually among children less than five years of age, according to estimates from the most recent State of the world's children.²³ We defined "supportive policy" as explicitly permitting CCM of pneumonia and "permissive policy" as the absence of a policy against the strategy.

Pneumonia treatment gap

The "pneumonia treatment gap" estimated the fraction of childhood pneumonia cases that failed to access appropriate treatment and were at greater risk of dying. We calculated this gap for each country using the estimated number of pneumonia cases annually²⁴ in each country multiplied by the estimated proportion of children not receiving appropriate case management for pneumonia, i.e. 100% minus the per cent reported to have sought appropriate care for cough and difficult or rapid breathing.²³

Results

Description of respondents

We received first-round questionnaires from 54 countries in Asia and Africa, which represented nearly all the pneumonia mortality (97%) and incidence (97%) in the original 60 MDG priority countries. Data were not received from Gabon, Sierra Leone and Somalia, and these countries were excluded from the analysis. Respondents included UNICEF country officers (45), national Ministry of Health officials (39), WHO country officers (16) and others (12). Most questionnaires had two (28) or three (17) respondents; WHO, UNICEF and the Ministry of Health completed only one jointly. We received 25 second-round questionnaires from the 31 countries that reported supportive policies or implementation of CCM of pneumonia in round one. Respondents included Ministry of Health officials (13), UNICEF country officers (12), WHO country officers (10) and others (4). Fifteen questionnaires had one respondent; five had two respondents, and WHO, UNICEF and the Ministry of Health completed five jointly.

Policy, implementation and plans

Most countries (45/54) reported policies endorsing C-IMCI, more commonly in Africa (34/38 countries) than in Asia (11/16 countries). Approximately one-third of countries (20/54) reported policies supporting CCM of pneumonia, and one-third (18/54) had no policy explicitly against the strategy (Table 1). The policy environment was thus permissive in most high mortality countries (38/54), especially in Asia. Three permissive countries reported CCM of pneumonia limited to: emergency settings (Uganda), nomadic or sparsely populated states (Sudan), and a specific NGO (Bangladesh).

Half the surveyed countries (27/54) reported some implementation of CCM of pneumonia (Table 1). More countries reported implementation of CCM of pneumonia than had explicitly supportive policies for the strategy. Approximately two-thirds of countries (26/38) with a permissive policy environment implemented CCM of pneumonia, more commonly in Asia than in Africa. One country implemented CCM of pneumonia despite a prohibiting policy, while four did not implement the strategy despite an explicitly supportive policy – all five in Africa.

Most countries currently implementing CCM of pneumonia (22/27) reported, at the time of data collection, intentions to expand the strategy, usually gradually (20), occasionally rapidly (2). Other country directions included implementation of what donors would fund (2), pilot-test (2) and no plan (1). Almost half of the 26 countries without current CCM of pneumonia implementation for which we have data (12/26) were interested in moving ahead with CCM of pneumonia through policy dialogue (4), pilot-test (2), gradual expansion (1), rapid expansion (3) or whatever donors would fund (2); but more (14/26) had no plan to implement the strategy.

Programme characteristics

The Ministry of Health was the lead agency in most of the 27 countries implementing CCM of pneumonia, especially in Asia, although NGOs and research institutions played important roles in some countries (Table 2). CHWs were usually community workers in Africa and government or NGO workers in Asia. A third of countries reported that their CHWs were paid, more commonly in Asia. About half of countries reported that clients paid for care, and of these, half offered fee exemptions, more commonly in Asia. Nearly all countries reported quality assurance through various methods.

Countries implementing CCM of pneumonia commonly delivered other curative interventions at the community level. All reported dispensing oral rehydration solution, but far fewer dispensed zinc to treat diarrhoea. Most countries delivered community-based treatment for malaria, except for four countries in Asia where the burden of malaria was low. Artemisinin combination therapies (ACT) were dispensed in about half the countries, either solely (5) or in addition to other antimalarials (8).

We obtained further details on the type of policy support for 24 countries initially reporting supportive policy for or implementation of CCM of pneumonia (Table 2). More than two-thirds of countries reported official written policies or official recommendations. In fewer countries, the strategy was locally recommended (3) or permitted in pilot areas (4).

Respondents from 24 countries reported the scale of CCM of pneumonia either as a percentage of administrative units or of population covered. Scale of implementation was limited in many countries, with four countries (Bangladesh, Cambodia, Ethiopia, Zambia) reporting < 1% coverage and an additional seven countries reporting < 10% coverage. Afghanistan, the Gambia, Malawi, Nepal, Pakistan and Senegal reported more than 50% coverage nationally. Implementation of CCM of pneumonia commenced early in some countries [the Gambia (1980), India (1990), Myanmar (1991), Pakistan (1994)], but more than half of responding countries had started CCM of pneumonia since 2004.

The 30 CHW cadres from 23 countries reporting implementation of CCM of pneumonia varied in educational background and training (Table 3). Asian countries employed more highly educated workers and provided longer training than African countries. Typical work settings also varied, with Asian CHWs more likely to work from government facilities, while their African counterparts more likely worked from home. Sixteen of the 23 countries reported a single CHW cadre, and 11 of these worked only in their communities – from home, community buildings, or both. They were less educated and less trained than their facility-attached counterparts. In two countries (the Gambia and Nepal), illiterate CHWs were commonly employed.

Most countries (19/22) used oral co-trimoxazole to treat suspected pneumonia, either solely (13) or with amoxicillin as an alternative (6); three countries used only amoxicillin. Four countries (Afghanistan, China, Madagascar and Nepal) used a 3-day treatment regimen. Nearly all CHWs (23 of 25 cadres in 20 countries) referred severe pneumonia, many (9/23) without administering the first dose.

Treatment gap

The 35 countries with the highest child mortality accounted for approximately 120 million cases of childhood pneumonia annually, of which 43 million children failed to see an appropriate provider – the "pneumonia treatment gap" (Table 4). An estimated 1.7 million children died from pneumonia in these countries, accounting for 85% of the world's estimated 2 million deaths due to childhood pneumonia annually.

We received information from 33 of these 35 highest mortality countries. Only 14 of the 33 reported permissive policies and implementation of CCM of pneumonia. These 14 countries accounted for much of the pneumonia burden among these 35 highest mortality countries (82% of cases, 70% of treatment gap and 63% of mortality), but the scale of implementation was often small. Other countries that had heavy burdens of childhood pneumonia and large treatment gaps reported piloting the strategy (Ethiopia) or were planning to implement it soon (Mozambique, Nigeria and Rwanda, among others). As of writing, some countries with high pneumonia burden and large treatment gaps (e.g. Angola, Cameroon, the United Republic of Tanzania) reported no plans to test or implement the CCM of pneumonia.

Discussion

Countries accounting for nearly half of all pneumonia deaths reported some CCM of pneumonia, with more progress in Asia than Africa. Reported plans to introduce or scale-up CCM of pneumonia underscore widespread acceptance of the strategy, no doubt spurred by international policy recommendations^18,19 and some mature programmes with over a decade of experience,^25,26 including some on a very large scale.²⁶ Indeed, the fact that Nepal is not among the 35 priority countries is probably due, in part, to its CCM of pneumonia programme, which currently covers 69% of children under five. Indeed, more than half of Nepal's expected pneumonia cases (56%) in 42 programme districts (of 75 districts) currently receive treatment, and CCM of pneumonia provides over half of that treatment.⁹

However, sustained effort is still needed to ensure that children receive appropriate treatment for pneumonia. Countries accounting for nearly a quarter of annual global pneumonia mortality (502 000), most with low coverage of facility-based treatment, do not implement CCM of pneumonia (Table 4). Where CCM of pneumonia is implemented, it often occurs on a limited scale or in pilot projects, commonly supported by international agencies and donors, especially in Africa.

Challenges in policy and programming

Health professionals in many developing countries believe that only health professionals at a health facility should treat pneumonia. A common reason for caution is concern about CHWs' possible misuse of antimicrobials and increased drug resistance.²⁷ However, CCM of pneumonia, which uses IMCI algorithms, could reduce both the improper use of antibiotics for cough and cold and increase their proper use for algorithm-positive pneumonia^28,29 provided that supervision reinforces CHW performance. We found that most countries support the distribution of antimalarials in the community, often the expensive ACTs. Implementation and policy discussions regarding introduction of antimalarials in the community can reinvigorate dialogue about CCM of pneumonia. Furthermore, accessible treatment needs to be made available for both pneumonia and malaria in the community; overlapping, indistinguishable presentations of malaria and pneumonia in malaria-endemic areas are well documented.^30–32

The challenge to increase coverage of appropriate treatment for childhood pneumonia is twofold: expanding and reinforcing existing facility-based health care and introducing and/or scaling-up CCM of pneumonia. Where CCM of pneumonia is most needed, it is most difficult to implement – in high-mortality countries with weak infrastructure, limited access to health services and dispersed, rural populations. In these areas, the existing weak support for facility-based care renders supporting CHWs all the more challenging.³³ Clearly, experience from similar contexts³⁴ and technical assistance are invaluable. Save the Children, CORE Inc. and the United States Agency for International Development (USAID)'s Basic Support for Institutionalizing Child Survival (BASICS), with support from UNICEF and WHO, are developing and testing "CCM Essentials", a forthcoming guide for district health officers to implement CCM of pneumonia and other infections (personal communication, Lynette Walker, 2008). Policy need not be a barrier for implementation of CCM of pneumonia. We found that official, written policies were, in fact, uncommon. Key documents, such as memoranda from Ministry of Health officials and/or adaptations of treatment guidelines³⁵ – as well as closely monitored pilot sites³⁶ – may speed the uptake of CCM.

Programmes differed greatly in their attributes, CHW profiles, scope and scale, as noted by others.³⁷ Programmes and projects in Asian countries were more likely to be led by the Ministry of Health, while in Africa they were more commonly led by academics or NGOs. Some countries, commonly in Asia, reported employing paid professional workers, while others employed community-based volunteers trained for shorter periods, specifically in CCM of pneumonia. Different contexts have different models.

Introducing, scaling-up and sustaining programmes will require careful consideration of the country context, including continued funding and organizational support. Some countries achieved scale through the Ministry of Health collaborating with multilaterals, bilaterals, NGOs and other partners for initial district-wide implementation in selected districts,^34,38 where all partners implemented a defined CCM package with standardized training materials, supplies, reporting mechanisms, and monitoring and supervision systems. The initial results and experiences could engage other partners and donors to expand this approach. In other countries, the CCM approach was adapted as national policy and incrementally expanded by the Ministry of Health.²⁶

Methodological limitations

We relied on respondents' definitions of CHWs, which included some cadres, especially in Asia, that were more professional than CHWs limited to their communities. The approximate geographical or population coverage of CCM of pneumonia programmes was difficult to assess; no standard measure was available that accounted for the population served. Our results surely overestimated the implementation of CCM of pneumonia, given that the coverage of the more highly trained CHWs was probably limited, that some of the cadres included in our analysis would not be considered CHWs by some definitions,^39,40 and that the reported scale was likely a best-case scenario. Responses from different experts in the same country were sometimes inconsistent. We reconciled these as much as possible. Some discrepancies may have resulted from policy and programme information that was changing.

We derived the "pneumonia treatment gap" from the product of modelled estimates of annual incidence of pneumonia and reported care-seeking for suspected pneumonia (defined in surveys as "cough" and "difficult or rapid breathing"). Care-seeking for suspected pneumonia to an appropriate health provider was used as a proxy for appropriate treatment in our analysis. This indicator has several limitations, including mothers' uncertain ability to recognize⁴¹ and recall⁴² signs of childhood pneumonia, and the lack of information about antibiotic treatment. New rounds of Multiple Indicator Cluster Surveys and Demographic Health Surveys are directly assessing the proportion of children with suspected pneumonia that received an antibiotic, but further methodological work is needed.

One might ask whether the international health community needs another pneumonia indicator in addition to expected cases per year, care-seeking, and deaths per year, especially one that derives from the first two, both of which are estimates. We propose the treatment gap as an intuitively understandable measure of need, especially for non-technical audiences. The gap characterizes the scale of the challenge for which CCM of pneumonia is likely to be part of the response, along with strengthening availability and quality of case management at existing service delivery points and mobilizing demand for such care. In addition, the treatment gap summarizes the challenge across countries with different levels of care-seeking. We recognize that the "percentage of expected cases treated" would perform similarly, assuming available, reliable treatment counts.

The way forward

Standardization is needed, including a definition of CCM of pneumonia, and indicators and measures of coverage that take into account the population needing the strategy. The global public health community needs an operational definition of this strategy to better describe, monitor and evaluate CCM of pneumonia programmes. Additionally, monitoring and reporting progress will require methodologically sound, standardized indicators of programme processes and progress, as well as national and local policies.

CCM of pneumonia has a broad and growing constituency: WHO, UNICEF, Ministries of Health, donors, academics and NGOs, including technical groups like BASICS, are important sources of technical support and advocacy. Countries with supportive policies and successful CCM programmes can provide technical support and exchange lessons learned with interested neighbouring countries. Development partners and countries will need to work together while implementing CCM of pneumonia programmes to address the key operational issues of microplanning, supply-chain management, logistics, supervision, training, coaching, and monitoring and evaluation. Operational research, pilot projects, and monitoring and evaluation results can guide introduction and scale-up of CCM of pneumonia. Where supportive policy for CCM of pneumonia is lacking, development partners and academic institutions should jointly advocate for policy change and support implementation. Momentum for community-based treatment of malaria should facilitate introduction of CCM of pneumonia. WHO, UNICEF and other technical assistance partners should support the development and adoption of policies, projects, programmes, indicators and tools for CCM of pneumonia, taking advantage of the momentum around community-based strategies and approaches as key to achieving MDG 4 and other health-related MDGs.²³

Acknowledgements

We thank Jasmina Acimovic (UNICEF-NY), Eric Starbuck (Save the Children), Martin Weber (WHO-Indonesia), colleagues at WHO and UNICEF regional offices, and colleagues at national MoH, UNICEF, WHO, BASICS and Save the Children offices.

Competing interests: None declared.

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(Submitted: 9 October 2007 – Revised version received: 11 March 2008 – Accepted: 12 March 2008)

1 Correspondence to David Marsh (e-mail: dmarsh@savechildren.org).
doi:10.2471/BLT.07.048462