Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria

1. Community Case ManagementOf Serious, Common, Childhood Infections in High Mortality Countries: Rationale, Experience, and Opportunities Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria Non-Governmental Organization Teleconference April 7, 2011 David R. Marsh, MD, MPH Senior Advisor, Child Survival Global Team Leader, Community Case Management

2. Outline • Rationale and definition • Experience • Programs • Research • Opportunities

3. Rationale

4. Causes of Child Death – 2008* *Slide courtesy of S Qazi and T Cherian, WHO/CAH • 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. Global WHO CHERG estimates, Black et al Lancet 2010

5. 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 % Source: WHO CAH department; WHO-UNICEF immunization coverage estimates

6. Irrawaddy Delta “Highway” (Myanmar)

7. 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

8. Definition

9. 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.

10. Sick Child Recording Form ASK LOOK DECIDE ACT: TREAT AT HOME ACT: REFER

11. Drugs & Equipment (Nicaragua) Spoons, timer, mixing containers, counseling cards, raincoat, forms Antibiotic, zinc, ORS, antipyretic

12. Encounter (Nicaragua) Counting respirations. Treatment Register

13. Health Worker with her Supervisor and her Supervisor’s Supervisor Supervision (Nicaragua) Supervision Checklist

14. Programs

15. 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

16. Research

17. 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

18. Provider Retention (7/05-8/06) Access to Case Management % 38/40 7/14 *SC trained 45 and certified 40 CCM providers

19. Use of Case Management (7/05-8/06) • 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 #

20. Quality of CCM Services %

21. Treatment Seeking for Cough and Difficult Breathing (1997-2006) Clinic-based treatment of pneumonia and malaria. CCM of pneumonia and malaria. * % 17% 58% 84% * = 200,000 untreated cases of childhood pneumonia, malaria, and diarrhea every year

22. Treatment Seeking for Cough and Difficult Breathing (1997-2006) Clinic-based treatment of pneumonia and malaria. CCM of pneumonia and malaria. * % CCM 17% 58% 84% * = 200,000 untreated cases of childhood pneumonia, malaria, and diarrhea every year

23. 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)

24. CCM Training in Ethiopia (2/11)

25. 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

26. Opportunities

27. 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

28. 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

29. Twa to te la 谢谢 (xièxiè) Photo by Cleis