1. Community-Based Treatment of Pneumonia (“CBT of P”) Technical basis, USAID strategy and the role of PVOs Child Survival and Health PVO Grants RFA Orientation 14 September 2004

2. Global burden of disease Mortality –21% of under-5 deaths are due to pneumonia –2 million under-5 deaths each year Potential lives saved –1.3 million of these deaths are preventable –577,000 lives could be saved by antibiotics alone Lancet, July 2004

3. Annual child deaths from pneumonia, malaria and diarrea by WHO region WHO 2000

4. Early childhood infections and growth Kg 0369121518212427303336 2 3 4 5 6 7 8 9 10 11 12 13 14 15 KEY ARI – Acute Respiratory Infection D – Diarrhea M – Measles FEVER – Fever AGE IN MONTHS Adapted from MATA, 1975 ARI M D D D D D D D D D D FEVER D D D D D D D D D D

5. Children with ARI symptoms taken to a health care facility Global LAC SSAANE E&E Source: Trends are estimates based on Demographic and Health Surveys, 1985-2000.

6. Unmet need for CBT 28% die without receiving any care outside the home Only 10% receive quality care in facilities

7. Evidence for CBT Meta-analysis (Lancet 2004) –Infant mortality All-cause reduced by 20% Pneumonia-specific reduced by 36% –Under-5 mortality All-cause reduced by 24% Pneumonia-specific reduced by 36% Cost-effectiveness (MBB Tool 2004) –Additional cost/person/year = $0.09 (Ethiopia)

8. Simplified algorithm Child with ARI sx’s brought to CHW Child <2 months Child 2-59 months Referred to facility Severe pneumonia Pneumonia URI AdviceCotrimoxazole

9. “(Virtually) Every child with pneumonia in a malaria-endemic area should receive effective treatment for malaria as well.” (CDC, UNICEF) Malaria/pneumonia symptom overlap “Fever in past 48 hours” (= malaria) “Cough with rapid breathing” (= pneumonia) Afebrile pneumonia

10. Nepal case study

11. Pneumonia cases treated by CHWs and health facilities in four program districts <20% 1991/92 62% 2000/01

12. Quality of care: Correct dosing of cotrimoxazole

13. Senegal case study

14. Results Appropriateness of management –95% of pneumonia cases correctly classified –97% correctly treated –69% of severe cases appropriately referred (additional 22% received cotrimoxazole) Effect on care-seeking –Nearly twice as many pneumonia cases were treated in intervention areas than in control areas (185 vs. 96 per 1000 population)

15. WHO/UNICEF Joint Statement “CHWs can be trained to assess sick children for signs of pneumonia; select appropriate treatments; administer the proper doses of antibiotics; counsel parents on how to follow the recommended treatment regimen; follow-up sick children; and refer them to a health facility in case of complications. There is strong scientific and program evidence to support the effectiveness of this approach.” WHO/UNICEF Joint Statement, “Management of Pneumonia in Community Settings,” May 2004

16. USAID’s CBT strategy: Global goals 1.Increase awareness and funding for CBT of pneumonia 2.Achieve >25% coverage of target population with high quality care in >10 of the 42 high- mortality countries by 2010 (“10 by 10” Initiative) 3.Contribute to evidence base for related interventions: integrated approaches to pneumonia and malaria, treatment of severe pneumonia, treatment in HIV high-prevalence areas, treatment of pneumonia and sepsis in children <2 months, private sector approaches

17. Regional goals Africa –The Big 3 (Nigeria, Ethiopia, DRC) –W. Africa through regional approach –Other countries as opportunities arise Southeast Asia –Cambodia South Asia –Bangladesh and India Latin America –Remote regions as appropriate

18. Country criteria Willingness of MOH to consider changing policy or to explore community- based approaches to improving access to treatment of pneumonia Existence or emergence of an appropriate cadre within the community or at the peripheral facility level with potential for large-scale implementation (e.g., greater than 25% of the populations at greatest risk) Functional drug management system at the peripheral level, or potential for improvement Adequate mechanisms for training, supervision and monitoring, or potential for improvement Poor access to health services or poor quality and utilization of services High burden of disease as a proportion of under-5 mortality Important contributor to global under-5 mortality Potential for influencing other countries Potential for contributing to an evidence base for related interventions Availability of appropriate donor and implementation partners

19. Country typology Countries that are willing to proceed and that only require operational guidance and funding (e.g., Tigray) Countries that are not yet convinced, but might be satisfied by evidence from within their region (e.g., Benin) Countries that are not yet convinced, and will require local proof based on a demonstration project (e.g., Mozambique) Countries that are opposed, and which will require extensive evidence from other countries and advocacy before even agreeing to a demonstration project

20. Existing early country efforts Bangladesh Benin Cambodia DR Congo Ethiopia Haiti India Madagascar Malawi Mali Mozambique Nigeria Senegal Uganda West Africa Zambia

21. Role of PVOs MOH Community PVOs USAID Synergy ! CORE Group BASICS 3 HARP RPM+

22. How can USAID help? Support for policy change (with WHO, UNICEF, World Bank, local USAID Mission) Technical assistance for programming, M&E, tools

23. How can CORE help? Sharing member experiences Drafting of a field guide for program managers Global, regional and national advocacy