Bill & Melinda Gates Foundation

Two Big Challenges to Prevent Under-Five Deaths from Pneumonia: Care Seeking and Treatment Compliance

November 12, 2013

Pneumonia kills more than 1 million children annually, causing almost 20% of all under-five deaths. Despite the availability of proven, cost-effective interventions to treat pneumonia—both in health facility and in the community—only 30% of children with suspected pneumonia in the least developed countries receive antibiotics. If these simple treatments were widely available and used for most episodes of pneumonia, the deaths of more than 600,000 children could be prevented in the next two years, accelerating achievement of Millennium Development Goal (MDG) 4.

Countries face challenges in scaling up health service delivery strategies, both clinical and community-based, to achieve health goals, and in estimating the resource requirements and financial implications of these strategies, especially for excluded populations. Efforts to strengthen health systems are severely underfunded in many countries, with inadequate resources to support retention of health workers; improvement of health information systems; universal access to essential medicines, vaccines, and technologies; and sustained good governance in the sector. 

Progress toward reaching the MDGs has been inconsistent within and across countries, with frequent neglect of the poorest groups (often girls and indigenous populations) and those lacking access to education (often populations living in remote areas). The time is ripe for a concerted global effort to end preventable child deaths from pneumonia in high-burden countries.

The United Nations Children's Fund (UNICEF) and USAID are spearheading "Committing to Child Survival: A Promise Renewed," a global movement through which more than 170 governments and countries have committed to ending all preventable child deaths by 2035. The UN Commission on Life-Saving Commodities for Women and Children, launched in 2012, includes within their mandate amoxicillin dispersible tablets—affordable medicine that can save millions of lives from unnecessarily deaths due to pneumonia. In conjunction with that effort, several of the highest burden countries are adopting ambitious plans to rapidly expand the proportion of children with access to these essential medicines, plans that highlight the need for coordinated interventions because many of the strategies to prevent and treat pneumonia and diarrhea in children are similar.

Moreover, in 2013, UNICEF and the World Health Organization launched the Integrated Global Action Plan for Pneumonia and Diarrhea (GAPPD), which is a coordinated, multi-level approach to addressing the two leading causes of under-five mortality, focusing on prevention, protectio, and treatment. Partners are working with countries to support inclusion of GAPPD’s key actions on pneumonia and diarrhea into country maternal, newborn, and child health plans for accelerated action to achieve MDG 4.1

On this World Pneumonia Day, we want to call the attention to two main constraints for the detection and correct treatment of pneumonia in children: care seeking and treatment compliance of caregivers for out-patients with pneumonia. We also want to emphasize the need to bring down these critical messages and initiatives from the global board rooms to village gatherings.

Care seeking
In much of the world, health systems have failed to improve parents' and care givers' knowledge of the signs and symptoms of pneumonia that indicate the need to seek attention from a health provider for their children. A recent MCHIP study looking at care seeking behaviors in 40 developing countries found that, in some countries, as many as a third of sick children are never taken to a health provider.2 Prompt care seeking is crucial to early detection of pneumonia, prompt treatment. and survival. How can we work together with, and empower, parents to prevent these preventable deaths? How can we empower caregivers to know that, it’s not fate, they change the course of the illness?
 
Treatment Compliance
In addition to parents recognizing the symptoms and signs of pneumonia and seeking care promptly, they need to ensure that their children complete courses of treatment in the right dosage. But what happens after they are given the recommended treatment with antibiotics? It has been shown that the level of compliance treatments at home, even with antibiotics, is extremely low. 

Some reasons include complicated procedures (like the need to split tablets, under or over diluting of suspensions, and keeping some medicine for a future episode once the child starts to feel better). One contributing factor to noncompliance is the cost associated with accessing care—either long distance to the health facility or if the drugs run out, the out of pocket cost of antibiotics. This could lead to caregivers rationing the medicine they receive.  

If we don't understand and help families address these ‘reasonable but dangerous choices, then we have no hope of being able to increase treatment compliance and, therefore, little hope of ending preventable child deaths by pneumonia. What is known about treatment compliance, what isn't known, and what can we do to reverse this critical situation? To understand the barriers, we have to address each family situation and help them solve the problem as part of treatment. Some of these challenges are being addressed, such as the advocacy for policy change to dispersible amoxicillin, which is easier to split and easily dissolves in water.
 
One important strategy available to address this complex situation is the global initiative of Integrated Community Case Management (iCCM) of childhood pneumonia and other prevalent diseases in children by community health workers (CHWs).  Learning from the oral rehydration solution revolution of the eighties, we need to engage a broader range of partners including artisans, community leaders and families. Pneumonia detection and early care seeking should be a community norm. 

In addition, tracking of progress should also be a community norm, with every member of the village knowing if a child survived or died from pneumonia. If these discussions are part of community gatherings, there will not only be accountability for progress, but also positive cohesion applied for early care seeking and treatment compliance. With many global initiatives to increase availability of antibiotics, CHWs can help assure families that they do not need to save medicines for the next episode.

 
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