EssentialMedicinesProgram:Pneumonia

December2016

PresentedbyAudreyBattu
Director,EssentialMedicines
abattu@clintonhealthaccess.org

Agenda

AbouttheClintonHealthAccessInitiative(CHAI)
PneumoniaInterventionsIntroductionandOverview
CountrySpotlights
Global
Ethiopia
Uganda
Nigeria

AbouttheClintonHealthAccessInitiative,Inc.(CHAI)
We are a global health organization
committed to strengthening integrated
health systems and expanding
access to care and treatment in the
developing world.
CHAIs solution-oriented approach
focuses on improving market
dynamics for medicines and
diagnostics; lowering prices for
treatment; accelerating access to
lifesaving technologies; and helping
governments build the capacity
required for high-quality care and
treatment programs.

Dedication to the
mission

Government
Leadership

Urgency

Our Values
Our Staff

We are driven by a set of values

that are fundamental to our work
and support our change-oriented
agenda.

Trust &
Transparency

Frugality

Humility

Entrepreneurship

For more information, please

visit: www.clintonhealthaccess.org.
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Agenda

AbouttheClintonHealthAccessInitiative(CHAI)
PneumoniaInterventionsIntroductionandOverview
CountrySpotlights
Global
Ethiopia
Uganda
Nigeria

Pneumoniaisthe#1killerofchildrenunder5inthedevelopingworld
In2015,pneumoniaclaimedthelivesofnearly
1millionchildrenundertheageof5
Proportionaldistributionofcausespecificdeaths
amongchildrenunderfiveyearsofage,20151
Pneumonia
16%

Effectivetreatmentexists,butaccessremainsan
obstacleformanyinthedevelopingworld
Prevention
Vaccines:Universalaccesstoexistingvaccines(for
pneumococcus&Hib)saveslives.However,many
deathsoccurbeforevaccinationcanbegin(inthe
neonatalperiod).

Treatment
Other(injuries,
measles,etc.)

Diarrhea
9%

27%

5%

Malaria
1% HIV/AIDS

Neonatalcauses
42%

Nonseverepneumoniashouldbetreatedwith
AmoxicillinDT;severepneumoniatreatmentrequires
oxygentherapy,parentalampicillin(orpenicillin)and
gentamicin
AmxDT:WHOrecommendsAmoxicillinDTfor1st
linetreatmentofpneumoniainchildren259m
Casemgmtcanreducemortalityby~40%and
AmoxDTshowsgreaterefficacycomparedto
Cotrimby415%4
Suppliedat<US$0.110.23/course5
Oxygen:Recommendedfortreatmentofsevere
pneumonia,canbemonitoredthroughuseofpulse
oximetry.

SeeReferencespageformoredetailedsourceinformation.1)Liu,etal.,2016;2)MSHandWHO,2014;3)CHAICoGSanalysis,2012;
4)Grant,etal.,2009;5)UNICEF,2012

CHAIiscurrentlyworkingatgloballevelandin3focalcountriestoincrease
accesstoandcorrectusageofpneumoniatreatment
GlobalDiarrhea&PneumoniaWorkingGroup

CurrentCHAIprogramsfocusedonpneumonia

Purpose:Acceleratetreatmentscaleup
across10highburdencountriesglobally,
accountingfor~60%oftotalglobalcases

Ethiopia

Membership:CochairedbyCHAI&UNICEF;
40+members(donors,NGOs,WHO,etc.)
Mechanism:Technicalassistance,resource
mobilization;forumtosharebestpractices

Scope: Oromia,Tigray,Amhara,SNNPregions
Goal:Increasedzinc,ORS,AmoxDT,POx,O2

Nigeria
Scope: Kaduna,Kano&Niger
Goal:Increasedzinc,ORS,AmoxDT,POx,O2

Uganda
Scope: Nationwidetargets,IntegratedChildHealth
Goal:Increasedzinc,ORS,AmoxDT,POx,O2,mRDTs

Additionalprogramsstartingin2017
India
Kenya
Tanzania

Diarrheaandpneumoniatreatmentofferperhapsthegreatestuntapped
Fivebroadareasemergeasprioritiesforinterventiononpneumonia
treatmentbasedonexistinggaps
opportunitiestofurtherprogresstowardsMDG4
1 Ensureanenablingpolicy
environment

SupportMoHtoadjustrelevantpolicies:
treatmentguidelines(amoxDT,SpO2),EML,other

2 Encourageearlycareseekingand Supportmotherstorecognize earlydangersigns

referralsforfastbreathing/LRTIs Encouragerapidcareseeking/discouragehomeTx
3 Improveaccuratediagnosisof
pneumoniaandhypoxemia

Ensureaccess toanduseofoptimal,existing
diagnosticattheirappropriatelevel
Respiratoryratecounters
Pulseoximetry
Acceleratedevelopmentofpromisingnewproducts

4 Improvemanagementofnon
severepneumoniawith
AmoxicillinDT

Developcompetitivelocalsupplybaseoflowcost
amoxDTw/appropriatepackaging
Encourageprivateproviderstorefertimely
Supportpublicsectorprocurement &supply
Educate appropriateprovidersonamoxicillinDTas
appropriatefirstlinetreatment

5 Improveadequatemanagement
ofsevereillnessatfacilitylevel

Expandavailabilityanduseofoxygenatfacilities
Train healthcarestaffonoxygentreatment
Optimizesupplysystemsforuseinlow
resourcesettings

Agenda

AbouttheClintonHealthAccessInitiative(CHAI)
PneumoniaInterventionsIntroductionandOverview
CountrySpotlights
Global
Ethiopia
Uganda
Nigeria

Global:FrontlineHealthWorkerKit&CaregiverKitforPneumonia

Opensource,freematerials
areavailableforallusersand
easytoadapttoalocal
context.
Helphealthworkersand
parentsunderstandthesigns
andsymptomsof
pneumonia.
Includeeducationalposters,a
caregiverflier,aflipchart
story,ahealth
worker training, an
adaptationguide,andare
availableindifferent
languages.

www.lifesavingcommodities.org/pneumonia
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Ethiopia:Diagnosisandtreatmentofpneumoniaisapriorityareaunderthe
NationalNewbornandChildSurvivalStrategyforthenextfiveyears
Challenges
Pneumonia is the biggest killer of children under five in Ethiopia, contributing to
18% of deaths1
Pneumoniaantibioticcoverageremainslowwithonly7%ofchildrenunderfivewith
acuterespiratoryinfection(ARI)receivingtreatment2
Oxygen availability is a vital component of combatting pneumoniarelated mortality
for newborns and under five, but only 2% of HCs have functional oxygen supply
system3
PulseoximeterstomeasureSpO2 levels arenotavailableinHealthCenters,while
only45%ofhospitalshaveitintheirpediatricwards3
OverallOxygenAvailability,HealthCenters
314
11%
TOTALHC

Manageoxygen
[33]

2%

0%

0%

Fullyfunctionalcylinder Functionalpulseoximeter Stafftrainedonproviding

available,
oxygentherapy,or
and/orconcentrator,
[6]
[0]
SOP/jobaidsforproviding
therapy,
[0]

1)NationalNewbornandChildSurvivalStrategyofEthiopia,20152020;2) EthiopiaDHS,2011;3)CHAIFMOH/PFSASurvey,2016

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Ethiopia:RecentlylaunchedalandmarkNationalOxygenandPulseOximetry
Roadmaptodramaticallyimproveaccesstolifesavinginterventions
KeyNationalTargets
FMOHaimstoreduceunderfivemortalitybymore
thanhalftoatleast29/1,000by2020:
Increasepneumoniaantibioticcoveragefrom
7%(2015)to80% (2020);1
EquipallHCs(~3,800)andPrimaryHospitals
(~1000)withoxygenconcentratorsby2020.2
EquipandensureallHCsstartusingpulse
oximetersbytheendof2018.2

KeyActivities
Policyoptimization,ensuringthatguidelineslist
theappropriatetreatmentanddiagnostics;
Systemsstrengtheningtodeliverchildhealth
commodities;and
Procurementsupport,includingsupplyplanning
andappropriatemixofoxygensources(cylinder,
concentrators,etc.),andsustainablefinancing.

KeyOutcomes
Increasedavailabilityofoxygen(O2)at
appropriatelevelsofcare;
Increasedavailabilityofpneumoniadiagnostic
equipmentatappropriatelevelsofcare;and
Afunctionalsupplychainmanagementsystem
inplacetosustainablydeliveressentialchild
commodities(pneumoniadiagnosticsandO2).

1)NationalNewbornandChildSurvivalStrategyofEthiopia,20152020;2)EthiopiaRoadMap,2016

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Uganda:Pneumoniaistheleadingcauseofchildmortality,pooraccessto
oxygenandpulseoximetryremainsachallenge
TheMOHintroducedanimplementationframeworkin2014

ScalingUpApproachestoProtect,Prevent
andTreat(PPT)DiarrhoeaandPneumonia
inUganda

Pneumonia
cases
1,750,0001

AvailabilityofO2concentratorsinmaternity/pediatricward3
Deaths
13,7002

1.6

4.6

%ofallsurveyedfacilities

11
100%

80%

13%
HCIV(n=31)

1)Rudan,etal.,2010;2)Liu,etal.,2016;3)CHAIUganda

GH(n=10)

RRH(n=6)

Average#units
/pedsward

Uganda:CHAIissupportingtheMOHinscalingupaccesstotreatment

Varietyof
symptoms

Care
seeking

Doesnot
presentwhen
mild

Supply
Missed
diagnosis

Wrong
treatment
prescribed

Treatment

Death
Notreferred
tohigher
levelfacility

Doesnot
presentwhen
severe

Casenot
managedwell

Case
mgmt

Progress

AmoxicillinDTScaleUp

ClosecontactwithMoHtopromotechangeof
guidelines
Contactwithsuppliersandlocalmanufacturesto
ensurequickimplementationassoonastheguidelines
areapproved

Referral
Poor
availabilityof
drugs

ImprovingReferral
Utilizationofpulseoximetersandappropriatereferral
atlowerlevelfacilities:
Baselinerevealedthat~1319%ofsuspected
severecaseswerereferredupwards

Kaabong
Yumbe

Moyo

Lamwo

Koboko

Diagnosis

Kitgum
Maracha
Adjumani

MOHisinvesting$1.6
milliontosupport
constructionof13new
oxygenplants,fora
totalof15nationwide.

Kotido
Gulu
Pader
Arua
Amuru
Abim
Moroto

Napak
Nebbi

Oyam
Lira

Buliisa

Kiryandongo
Apac

Katakwi
Amuria

Dokolo

Nakapiripirit

Amudat
Masindi

Soroti
Kumi

Kapchorwa

Hoima
Nakaseke

Pallisa

Sironko

Kyankwanzi
Kamuli

Kaliro

Kibaale

Namutumba

Luwero
Kiboga

Nationalworktoimproveoxygenavailabilityandutilization

Kabarole

Jinja
KAMPALA

Mubende
Kyeggegwa

Mukono

Mityana

Kamwenge

Kasese

Mayuge

Wakiso

Gomba
Butambala
Sembabule
Mpigi
Ibanda
Kalungu
Kiruhura

Lyantonde

Quantificationofnationaloxygendemand
PreparationofhighlevelcurriculumforCME
PreparationofastrategicplanforoxygenscaleupinUgandatobe
endorsedbytheMinistryofHealth
Oxygenutilizationinhighlevelfacilities(orderingsupport,mentorship
key,CMEs)

Tororo

Iganga

Bugiri

Kyenjojo

Bukomansimbi

Bushenyi
Lwengo

Masaka

Mbarara
Kalangala

Rakai
Isingiro
Ntungamo

Kabale
Kisoro

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Nigeria:Pneumoniaisthesecondleadingcauseofunder5mortality,and
casefatalityratesaretwicetheaverageforhighburdencountries
Pneumoniaepisodes(millions)1
Pneumonia
cases
7,340,0001
35

Deaths

133,5002

Nigeriasseverepneumonia
CaseFatalityRateistwice
theaverageforotherhigh
burdencountries(15.9% vs.
7.1%)

1)Rudan,etal.,2010;2)Liu,etal.,2016

Nigeriaisthesecondhighestburdencountryafter
India,with7.3millionepisodesperyear

Nigeriarepresents9% ofpneumoniaepisodes
globally,but19% ofpneumoniadeaths

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Nigeria:CHAIissupportingFederalandStateMoHstoimproveoxygen
availabilityinsecondaryhealthfacilities
Optimizepolicy
SpO2 andO2 therapyinNatltreatment
guidelines,StandingOrders
PedsO2 andPOxinstateandfederalEMLsand
EELs

Kano
Kaduna
Niger

Increaseavailability
DevelopstatelevelO2 supplyandmaintenance
strategies
Resourcemobilizationforprocurementand
distribution
>50%SHFsw/O2 andPOxinpedswards

Institutionalizeuse

SupportCMEs,clinicalgovernanceenforcement
viaStateHospitalManagementBoards
20ppIncreaseinSHFO2 Use
40ppIncreaseinSHFPOxuse

Kano,Kaduna,andNigerstatesaccount
for>20%ofpneumoniaepisodes
nationally

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Pleasejoinwithusaswecommittoincreasingthenumber
ofchildrenreceivingtreatmentforpneumonia
1
Supportgovernments
withsmartandtargeted
investmentstohelp
thembuildontheir
successes.

3 Workwiththe
technologycommunity
toinnovate,focusing
onsolutionsfor
resourcelimited
settings.

Increaseaccessto
vaccinesandessential
medicines,including
AmoxicillinDTandoxygen.

4
Providehealthcare
workerswiththe
simpletoolsthey
needtoaccurately
diagnoseandenable
treatment.

Properlyequip
caregiverswiththe
knowledgetheyneedto
actonbehalfoftheir
children.
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References
Belle,J.,Cohen,H.,Shindo,N.,Lim,M.,VelazquezBerumen,A.,Ndihokubwayo,J.B.,&Cherian,M.(2010,May4).
Influenzapreparednessinlowresourcesettings:alookatoxygendeliveryin12Africancountries.JIDC(Journalfor
InfectioninDevelopingCountries).Retrievedfromjidc.org/index.php/journal/article/view/20818088/412
BMGFandUSAID.(2014).TheGrowingMarketforAmoxicillinDispersibleTablets:OpportunityAssessmentforPotential
Manufacturers.Copenhagen.Retrievedfromhttps://www.unicef.org/supply/files/07_YoungLee.pdf
CHAINewMarketOpportunitiesTeam.(2015).IncreasingaccesstoMedicalOxygeninlowresourcesettings.
Duke,T.,Graham,S.,Cherian,M.,Ginsburg,A.,English,M.,Howie,S.,...UnionOxygenSystemsWorkingGroup.(2010,
November).Oxygenisanessentialmedicine:acallforinternationalaction.TheInternationalJournalofTuberculosis
andLungDisease.Retrievedfromncbi.nlm.nih.gov/pmc/articles/PMC2975100/
Grant,G.,Campbell,H.,Dowell,S.,Graham,S.,Klugman,K.,Mulholland,E.,...Qazi,S.(2009,March).Recommendations
fortreatmentofchildhoodnonseverepneumonia.TheLancet.doi:dx.doi.org/10.1016/S14733099(09)700441
Liu,L.,Oza,S.,Hogan,D.,Chu,Y.,Perin,J.,Zhu,J.,...Black,R.(2016,November10).Global,regional,andnational causes
ofunder5mortalityin200015:anupdatedsystematicanalysiswithimplicationsfortheSustainableDevelopment
Goals.TheLancet.doi:dx.doi.org/10.1016/S01406736(16)315938
MSHandWHO.(2014).InternationalDrugPriceIndicatorGuide. Retrievedfrom
erc.msh.org/mainpage.cfm?file=1.0.htm&module=DMP&language=English
Rudan,I.,O'Brien,K.,Nair,H.,Liu,L.,Theodoratou,E.,Qazi,S.,...Campbell,H.(2013,June).Epidemiologyandetiology of
childhoodpneumoniain2010:estimatesofincidence,severemorbidity,mortality,underlyingriskfactorsandcausative
pathogensfor192countries.JournalofGlobalHealth.doi:dx.doi.org/10.7189/jogh.03.010401
UNICEF.(2016,November).Symptomsofpneumoniacareseeking. RetrievedfromUNICEFData:
data.unicef.org/topic/childhealth/pneumonia/
UNICEFSupplyDivision.(2013).AmoxicillinDispersibleTablets(DT):ProductProfile,AvailabilityandGuidance. Retrieved
fromunicef.org/supply/files/Amoxicillin_DT_Product_Profile_and_Supply_Update.pdf

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