Kenya Best Practice Pneumonia Demonstration Projects

KENYA BEST PRACTICE PNEUMONIA DEMONSTRATION PROJECTS

DRAFT PROPOSAL OF THE PNEUMONIA AND DIARRHEA WORKING GROUP[1]

in support of

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, 107,000 children in Kenya did not reach their 5th birthdays putting Kenyaon the list of countries with the highest burdens of child mortality. Pneumonia is the single largest cause of death among children in Kenya, causing an estimated 20,000 (17%) under 5 deaths and around 9 million episodes of sickness every year at an enormous cost to children and families.[2] While it is true that the majority of child pneumonia deaths can be prevented with cost effective vaccines andlow cost antibiotics, the pneumococcal vaccine was just introduced in Kenya in 2011 and only 50% of children with suspected pneumonia are treated with antibiotics. In addition, Kenya’s relatively low rates of exclusive breastfeeding (32%), access to improved sanitation (30%) and drinking water (50%) and high rate of undernutrition (35% children are stunted)are all factors contributing to child pneumonia deaths.[3] With concerted and coordinated action on these fronts most of the 20,000 pneumonia deaths could be averted taking Kenya one big step closer to achieving Millennium Development Goal 4 (MDG4).[4]

Countdown to 2015: Maternal, Newborn and Child Survival. Kenya: The 2012 Report.

THE OPPORTUNITY

To accelerate progress to MDG4 in the three years remaining to 2015, the Government of Kenya is driving progress on both the prevention and treatment sides of the pneumonia challenge. The pneumococcal vaccine was introduced in 2011 and the Ministry of Public Health and Sanitation has endorsed aScaling Up Strategy for Essential Treatments in Children Under Five Years[5],whichlists the actions needed to achieve universal coverage of essential medicines to treat pneumonia and diarrhea in the context of integrated Community Case Management. The Government’s goal is to “transform the landscape for diarrhea and pneumonia treatment of children in Kenya” by ensuring that 80% of children with suspected pneumonia receive the recommended antibiotic treatment – amoxicillin in dispersible tablet form.

Key elements of the Scale Up Strategy include:

PRIORITY ACTIONS TO SCALE UP ACCESS TO PNEUMONIA TREATMENT IN KENYA

1) Educating Families & Caregivers
-Teach families and caregivers about pneumonia, the seriousness of the infection and how to recognize the danger signs (fast breathing and chest “indrawing”)
-Encourage families to seek care outside the home from qualified health providers quickly (currently 50% of children with pneumonia are treated at home)
-Educate families about amoxicillin dispersible tablets, how they work and the importance of completing a full course of treatment
-Introduce behavior changecampaigns targeted to the most vulnerable families and to the health providers who treat the majority of pneumonia cases
-Support programs that empower mothers to improve the health of their children / 2) Supporting Private Sector Provision
-Train private health providers, particularly pharmacists, tobetter manage childhoodpneumonia (33% of children with suspected pneumoniaare taken tothe private sector; 21% to pharmacies and shops and 12% to private doctors)
-Increase the supply of quality, affordable amoxicillin dispersible tablets
-Increase the relative affordability of amoxicillin dispersible tablets compared to other antibiotics (e.g. cotrimoxazole)
and common pneumonia treatments / 3) Supporting Public Sector Provision
-Trainand equip Community Health Workers to diagnose and treat pneumonia with amoxicillin dispersible tablets
-Improve forecasting, procurement and distribution of quality, affordable amoxicillin dispersible tablets in the public sector
-Train and equip hospital and facility staff to treat severe pneumonia with recommended antibiotics and oxygen where necessary
-Upgrade facilities to diagnose and treat severe pneumonia including provision of pulse oximeters and access to oxygen concentrators
4) Diagnostics
-Increaseuse of easy-to-use and effective respiratory rate timers in public
and private sectors
-Increase use of pulse oximetry in facilities and access to oxygen delivery equipment, especially in the “pneumonia friendly facilities” designated by the Government / 5) Local Manufacturing
-Work with pharmaceutical companies
to increase local manufacturing, marketing and distribution of quality, affordable amoxicillin dispersible
tablets
- Offer fasttrack registration for locally manufactured amoxicillin dispersible tablets that meet quality and price targets
-Offer “umbrella brand endorsement” for locally manufactured amoxicillin
dispersible tablets that meet quality and price targets
-Work with manufacturers to distribute dispersible amoxicillin tablets to rural areas / 6) Regulatory & Policy Changes
-Allow Community Health Workers to dispense amoxicillin dispersible tablets
-Disseminate pneumonia policies, standards and treatment
guidelines throughout the public and private health sectors
-List amoxicillin dispersible tabletson all Essential Medicines and Drug Lists
-Better monitor the quality ofantibiotics being used to treat child pneumonia
-Remove regulatory barriers to local pharmaceutical production 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)

BEST PRACTICE PNEUMONIA DEMONSTRATION PROJECTS

To support the introduction of the pneumococcal vaccine and the implementation of the Government’s Scaling Up Strategy for Essential Medicines, we propose that Best Practice Pneumonia Demonstration Projects be considered in Kenya. By combining the most effective pneumonia prevention, diagnosis and treatment interventions in the geographic areas with the highest concentrations of child pneumonia deaths, the Projects will seek to demonstrate how to accelerate child pneumonia mortality reductions and achieve efficiencies in the delivery of healthcare to children through better coordination across programs. The Projects would also provide the Government with an opportunity to implement the recommendations of the United Nations Commission on Life-Saving Commodities for Women and Children as they relate to amoxicillin dispersible tablets, ORS, and potentially other commodities (e.g. chlorhexidine and injectible antibiotics for neonatal infections).

Target Provinces could be selected from those that have successfully introduced the pneumococcal vaccine; from those that have the highest concentrations of under 5 deaths and/or from those districts that are targeted by the Government for accelerated introduction of integrated Community Case Management.[6] Western and Nyanza are the Provinces with the highest numbers of under 5 deaths (Nyanza has a population of 5.4 million and a Child Mortality Rate of 149 and Western has a population of 4.3 million and a Child Mortality Rate of 121). It may also be worth considering a Project in Rift Valley, which has a lower Child Mortality Rate (59) but an extremely large population (10 million). 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 (across several Provinces), (b) better coordinate the delivery of vaccines with the integrated community case management of pneumonia and diarrhea, (c) stimulate the development of local manufacturing of amoxicillindispersible tablets, (d) target the providers of pneumonia treatment who provide care for the majority of children, (e) test best practice approaches to the diagnosis of pneumonia with the goal of improving treatment outcomes and reducing healthcare costs (i.e. by reducing wastage of oxygen), (f) test innovations in pneumonia prevention and treatment, including respiratory rate counters, pulse oximeters, oxygen concentrators and user-friendly packaging of amoxicillindispersible tablets and g) rigorously and independently monitor and measure impact.

Specifically the Projects in Kenya 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
• Explain to families the importance of having children immunized with the measles, Hib 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 public services and where appropriate incentives (e.g. vouchers, conditional cash transfers) for seeking care from private providers

2. Prevention

• Increase coverage of the measles, Hib 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. exclusivebreastfeeding, 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, soapetc)
• Maximize uptake of prevention commodities with proven strategies (e.g. free trials, time payments, rights to return and rights to stop payments)[7]

3. Treatment

• Introduce quality, affordable amoxicillin dispersible tables, locally manufactured where possible
• Train and equip frontline health workers in both the public and private sectors to better manage childhood pneumonia with amoxicillin dispersible tablets
• Provide easy-to-use respiratory rate counters to health providers
• Train frontline health workers to refer very sick children to facilities where 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 treat children with pneumonia including better access to pulse oximetry and oxygen
• Introduce community-based monitoring of public and private healthcare providers to improve service utilization and health outcomes for children[8]

4. 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)

5. Impact

• Rigorously and independently monitor and measure impact on treatment outcomes and healthcare costs 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 Provinceswith the greatest number of child pneumonia deaths and mobilize the right set of public and private partners to drive uptake of interventions on both the prevention and treatment sides – working together for collective impact.[9] 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 integrated community case management. These Projects can build on the work of child health partnerships already active in Kenya, especially USAID’s APHIAplus (AIDS, Population and Health Integrated Assistance program) where PATH is a lead partner in Nyanza and Western Provinces.

Other potential partners include:

Absolute Return for Kids,[10]African Medical and Research Foundation, bilateral development agencies (e.g. NORAD, CIDA, DfID, DANIDA), Bill and Melinda Gates Foundation, Children’s Investment Fund Foundation, Clinton Health Access Initiative, GAVI, GFATM, Health Partners International, Lutheran World Relief, Micronutrient Initiative, International Vaccine Access Center, Inter-Religious Council of Kenya, International Refugee Commission, John Snow International, Kenya Red Cross, MCHIP, Kenyan pharmaceutical companies, JHPIEGO, PSI, FHI-360, UNICEF, WHO, World Vision International, Malaria No More 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 andMDG Health Alliance

1

[1] The Pneumonia and Diarrhea Working Group is chaired by UNICEF and the Clinton Health Access Initiative and supports 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 at the Child Survival, Call to Action in June 2012, the recommendations of the UN Commission on Life Saving Commodities for Women and Childrenand the Integrated Global Action Plan for Pneumonia and Diarrhoea, by WHO/UNICEF in April 2013, and are in support of the United Nations Secretary-General’s, Every Woman, Every Childmovement

[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

[5] Ministry of Public Health and Sanitation, December 2011

[6]Kenya Demographic and Health Survey 2008-09

[7] 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

[8]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

[9] 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. SeeStanford Social Innovation Review, Winter 2011