Ensuring children have the treatment they need to fight pneumonia 

 

Imagine your child has been having breathing difficulties with a cough for a few days, and she’s not getting better. You hold her in your arms as you make your way to the clinic, which is hours from where you live. She has pneumonia, but the lifesaving treatment she needs isn’t available.

Without the right medicine, your daughter’s condition worsens and, within days, her infection becomes severe — leaving her gasping for breath. If she doesn’t get to a hospital soon and get the treatment she needs, she could die.

This scenario is one that too many families continue to face — particularly in remote areas in low- and middle-income countries.

No child should die from a preventable and easily treatable disease, such as pneumonia.

Fortunately, in the last decade, more and more children have been surviving past their fifth birthday. Global investments and scientific advancements have led to declining death rates from AIDS, tuberculosis and malaria — which shows how much can be accomplished when the global community rallies behind common goals to deliver proven and impactful interventions.

Yet, even with the tools and resources we have to defeat it, pneumonia remains the leading infectious killer of children under 5 years old. In 2016 alone, pneumonia killed more than 800,000 children under 5.

A simple solution exists — amoxicillin dispersible tablets (amox DT). Amox DT is the preferred treatment for non-severe pneumonia in children under 5, as recommended by the World Health Organization (WHO). Amox DT is effective, lightweight, easy to transport, and simple to accurately dose. It’s also relatively affordable at about $0.50 USD per course of treatment.

However, making sure this medicine is consistently accessible to the children who need it is complicated. The underlying barriers to access vary from country to country. But ensuring a country has the funding it needs to buy and maintain a steady treatment supply is a critical factor.

Results at a glance

Pneumonia has been a particularly vexing problem in Tanzania — accounting for 15% of child deaths in 2016. The government has been able to achieve significant declines in child mortality rates for malaria and HIV/AIDS in recent years, but rates for pneumonia have only dipped slightly. With its goal of reducing child mortality by 80% by 2030, the government has prioritized efforts to address childhood pneumonia.

The government’s commitment has made Tanzania an important learning case. Since 2015, Results for Development has been supporting the government of Tanzania in implementing a holistic market shaping program to address the underlying systemic factors affecting whether amox DT is available at a health facility and if it’s accurately prescribed to the children who need it. This story highlights what progress the government has made (and how):

Read on to find out how the government achieved these results in a few short years — and hear from the change agents who made it possible.

A funding crisis in Tanzania

As part of its efforts to reduce childhood deaths from pneumonia, the government of Tanzania began updating its guidance to health care providers in 2015 to ensure that amox DT would be used as the first line of defense against the illness. But just as this process started, external donor funding for amox DT was about to end. Donor programs that previously funded, purchased and distributed amox DT in Tanzania were winding down — and no transition plan had been developed to address this funding gap.

Without an influx in funding, the supply of amox DT in Tanzania would have quickly depleted — leaving millions of children without treatment.

To prevent any interruptions in coverage, Results for Development (R4D) worked to identify new sources of financing for amox DT and secured funds for approximately 6 million courses of pneumonia treatment. R4D also proposed a distinct approach in supporting the government of Tanzania — one that focused on strengthening the capacities of key government agencies and other market aspects to ensure sustainable access to amox DT long after the program ends.

As part of this approach, R4D worked closely with a range of government partners in Tanzania, including the Ministry of Health, Community Development, Gender, Elderly and Children, to develop a co-financing plan for the government to gradually scale up its funding as donor funding gradually scaled down. This plan provided transparency on the portion of amox DT funding the Ministry of Health could expect to receive support on, and the share that was expected to be mobilized domestically year over year. Moreover, it was an important step toward the long-term goal of sustainable financing for amox DT.

Results: Through the combined contributions of R4D and the government of Tanzania, more than 100 million tablets of amox DT entered the public health system between 2017 and 2019, avoiding an emergency stockout and ensuring more consistent supplies of this lifesaving medicine.

Avoiding stockouts & oversupply: ensuring medicine is available when it’s needed

Dr. Ntuli Kapoglowe, program director of health, social welfare and nutrition services for the President’s Office – Regional Administration and Local Government (PO-RALG)

Dr. Ntuli Kapoglowe, program director of health, social welfare and nutrition services for the President’s Office – Regional Administration and Local Government (PO-RALG). Photo © Results for Development/Kelly Toves

Increasing access to amox DT isn’t as simple as securing funding. Knowing how much amox DT to order is a complex task that requires information to be analyzed from multiple data sources.

“To have a constant supply of medicine and to avoid stockouts, you need skilled personnel with good quantification and forecasting skills,” said Dr. Ntuli Kapoglowe, program director of health, social welfare and nutrition services for the President’s Office – Regional Administration and Local Government (PO-RALG).

Dr. Ntuli oversees approximately 7,500 health facilities in the country. It’s a huge job, he said, that requires good information systems and constant communication across regional- and district-level health facilities, the Ministry of Health, MSD and PO-RALG.

For the past 15 years, the government has been working hard to ensure consistent supplies of lifesaving commodities, including amox DT. But one hurdle that has been difficult to overcome is accurate quantification.

“If you don’t focus on improving quantification, you may under-plan or over-plan for medicine and you may end up with expired supplies,” he said. “The quality of data is also important.”

To address this issue, R4D worked with Dr. Ntuli and other government partners to improve Tanzania’s quantification methodology to more effectively predict demand of amox DT. This work focused on expanding the forecasting data to include additional age demographics and incorporating consumption data to reflect actual historic demand into its annual quantification process. For example, in 2019, the previously-used forecast methodology estimated that 27 million tablets would be needed annually; whereas the more complete approach, which accounted for actual consumption and other illnesses that amox DT treats, projected a need of 38 million tablets. After a robust discussion, the government selected the more complete approach to guide their procurement decisions — recognizing that the previous method would have under-anticipated the actual volumes needed for the country.

Results: With more accurate quantification processes, the Tanzanian government is able to better predict an appropriate amount of amox DT to budget for and order. These improvements can lead to fewer shortages or stockouts and a smaller chance of over-ordering, which results in expired supplies. By the end of 2017, 60% of health facilities in Tanzania had amox DT available on their shelves, which was a 30% increase over the previous year.

Ensuring government-led amox DT procurement

Mr. Laurean Bwanakunu, director general of Tanzania’s Medical Stores Department, which procures and delivers medicine and health supplies to health facilities in the country. Photo © Results for Development/Sala Lewis

With funding secured and improved quantification processes in place, R4D then provided support to the government of Tanzania to order its first shipment of amox DT. This was a change from the previous practice of relying on external procurement agencies.

The government agency responsible for procurement of medicine and health supplies is the Medical Stores Department (MSD). And, as the director general, it’s Laurean Bwanakunu’s job to oversee MSD’s role in buying and delivering high-quality, affordable health products and medicines, including amox DT.

“One of the things that keeps me motivated is getting medicines to hard-to-reach, rural areas,” he said.

The first step was encouraging manufacturers of high-quality amox DT to register in Tanzania.   R4D worked with partners to develop business cases to encourage manufacturers to enter the Tanzanian market. The business cases helped to demonstrate to suppliers that there was existing demand for amox DT and helped to clarify the registration process in Tanzania. Once the suppliers applied to the Tanzanian government for registration approval, the Ministry of Health worked to ensure the evaluation process was done in a timely manner. Having multiple high-quality manufacturers registered was an important step since it leads to improved supply security and competition can help drive prices down.

Next, R4D supported MSD in the tender and bid process for amox DT. This required developing new systems and processes within MSD to ensure: the tender (request for bids) was issued at the right time and with the right volumes; bids are received; bids are properly evaluated; and a purchase order is placed and paid in full. This is a complex process that is then repeated multiple times a year.

Bwanakunu appreciates R4D’s approach of working with and through the government and existing infrastructure.

“Even if you leave, the system will continue,” he said. “That’s the key to long-term impact.”

Results: As a result of these efforts, there are now five amox DT manufacturers registered to sell amox DT in Tanzania. Additionally, in April 2018, the first shipment of amox DT funded by the government of Tanzania and procured by MSD was distributed to public health facilities. In 2019, they purchased and distributed another shipment.

Improving diagnostics and treatment for pneumonia

At this Accredited Drug Dispensing Outlet (ADDO) in Dar es Salaam, owner Ester Shoo (L) and staff member Esther Andrews (R) provide R4D’s Tanzania team with a look at their backroom inventory. Alongside the market shaping program, R4D has been supporting the government in conducting monitoring and evaluation activities to better understand misdiagnosis rates and health care providers’ prescription behavior. Photo © Results for Development/Sala Lewis

While ensuring that amox DT is consistently available in health facilities is necessary to lower child deaths from pneumonia, it is not sufficient. Mortality reduction requires health care providers to accurately diagnose pneumonia in children and then prescribe amox DT for treatment.

An important step in shifting provider preference to amox DT over other less effective treatment options, involved updating key regulatory documents such as the country’s Standard Treatment Guidelines, Pediatric Standard Treatment Guidelines and the Accredited Drug Dispensing Outlet (ADDO) Drug List so that amox DT was listed as the recommended treatment for non-severe childhood pneumonia.

But even after doctors began prescribing more amox DT and demand increased, there was no robust data on whether health care providers were accurately diagnosing pneumonia patients.

To address this, R4D worked with the Tanzanian government and local partners to conduct a clinical study in three regions of Tanzania in 2017 that found that a large portion of children with pneumonia are not correctly diagnosed. In fact, only 1 in 5 children with pneumonia — as confirmed by a lung ultrasound examination — who went to a public health facility was correctly diagnosed by their health care provider as having the illness.

To improve provider diagnosis and prescription behavior, R4D and the Ministry of Health piloted behavior change communication interventions in 39 public health facilities in Dar es Salaam and Morogoro. The interventions, which ranged from remote clinical mentoring, clinical mentoring using case studies, mobile messaging and visual aids (in the form of job aids and posters), were shown to be feasible and were correlated with some improvements in provider knowledge.

Results: The vast majority of treatment policies have been updated. Additionally, the government of Tanzania now has greater clarity on rates of accurate diagnosis and prescription for childhood pneumonia.

Looking ahead

This co-designed, co-implemented program with the government of Tanzania has, in a relatively short time, led to greater availability of amox DT in public health facilities and a shift among health providers in amox DT being their preferred treatment for pneumonia. The substantial shift in provider preference toward amox DT is notable because it occurred alongside the 30% increase in amox DT availability and a 23% decrease in stockouts.

With stronger systems in place to finance, procure and deliver childhood pneumonia treatments to health facilities across Tanzania, the government is ensuring that a mother will be able to provide her child the medicine she needs at the exact moment she needs it. Working with and through the government ensures these processes will continue long after the program ends.

While many achievements have been made, in the coming years, R4D will continue to support government and other partners to ensure even higher levels of amox DT availability in the public sector and private sector and to secure sustainability so that treatment gets to those who need it.

Increasing access to childhood pneumonia treatment

R4D is supporting partners at the global and country levels to urgently address the lack of effective access to lifesaving pneumonia treatment for children.

Photo © Brant Stewart/RTI/USAID

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