EVERY WOMEN EVERY CHILD UN COMMISSION ON LIFE-âSAVING

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3.4.2 Amoxicillin tablets for treatment of pneumonia in children Problem statement Childhood pneumonia, often of bacterial origin, can easily be fatal when occurring in rural areas without access to immediate diagnosis and treatment. Newly developed child-‐friendly antibiotic treatment is now available in the form of amoxicillin dispersible tablets (tablets that easily dissolve in water, replacing bulky antibiotic syrup in glass bottles). Specific issues identified Provider issues: -‐ Pneumonia diagnosis is subject to barriers stemming from (i) the limited availability of respiratory rate counters, (ii) a lack of training to effectively use respiratory rate counters, resulting in user error, and (iii) design deficiencies of respiratory rate counters. Amongst children treated for respiratory illness (including pneumonia), only 33% were assessed for fast breathing (96% of private providers did not ask if the child has difficult or rapid breathing). Misdiagnosis can be fatal; one study showed that approximately 37% of fatal pneumonia cases were misdiagnosed as malaria. -‐ Inadequate private providers' knowledge and behavior: Private sector providers, who provide the majority of care for pneumonia in Uganda, have little incentive to perform differential diagnoses and often prescribe more expensive medicines, sometimes in partial doses. Public provider knowledge is also often poor. Formulation/ market shaping: There is a lack of availability of dispersible Amoxicillin in the private and public sectors. In the public sector, in the 45 districts covered by SURE, Amoxicillin caps was only available in 75% of HC2 and 78% of HC3 during the last quarter of 2012. For facilities that have been out of stock at least one day, the average stock out over the last 3 months lasted 25 days at HC2 and HC38. No data is available dispersible Amoxicillin specifically. Quality: Lack of an active coordination mechanism between the partners: A significant number of stakeholders have an interest in the pneumonia diagnosis and treatment: public, private for-profit and private not-‐for profit organizations. There is a risk of overlaps, inefficiencies and loss of opportunity if these efforts are not well harmonized and coordinated Evidence/ regulatory issues: Lack of a conducive regulatory framework for Amoxicillin: Amoxicillin is not the recommended 1st line treatment for pneumonia in the current clinical guidelines. Amoxicillin dosing in children does not tally with WHO recommendations. Despite the fact that Amoxicillin is included in the Essential Medicines List and as such included in the kit pushed to HC II and VHT, Amoxicillin is only recommended at HC II in EMHSLU 2012.
Product development/ market shaping: Affordability of Amoxicillin: Although the cost of Amoxicillin is relatively low compared to other drugs, the cost may still be a barrier to access for the poorest. In addition, the scale-‐up of Amoxicillin supply in the public sector could become -‐ if price remains unchanged -‐ an unsustainable burden for the Govt. Awareness/ demand Treatment-‐seeking is often delayed: the median interval between symptom recognition and treatment-‐seeking amongst children with pneumonia was found to be 2 days, while it takes an average of 7 days before severe cases arrive at hospital. As the progression from first symptoms of pneumonia to severe disease can be rapid, prompt initiation of treatment is crucial: the case-‐fatality rate in untreated children can exceed 20%, and death can occur after 3 days of illness. Implementation plan a) Immediate plan • Procurement of user-‐friendly breathing counters for public health center and VHT. Supply of user-‐friendly breathing counters to private providers. Development of mobile-‐phone-‐based application to measure fast-‐breathing. • Train private providers in the diagnosis and treatment of Pneumonia and promote Amoxicillin as the 1st line treatment in the management of Pneumonia. Create & print & distribute training materials for private health workers (job aids, video, …). Train, support and supervise private providers in integrated case management of child pneumonia (diagnosis and treatment). Increase detailing efforts by pharmaceutical distributor to private providers • Increase availability of Amoxicillin dispersible tablets in the public sector. Support the NMS to improve the national Logistics Management Information System so that the quantification of consumption, volumes issued and costs is appropriately tracked. This will enable regular revise of the essential medicine kit to take into account volume increases correlating with demand generation efforts, and avoid stock outs. • Create a conducive regulatory environment for Amoxicillin. Update the Clinical Guideline to include Amoxicillin as the recommended 1st line treatment for pneumonia. Update the clinical guideline and align the recommended dosing on WHO guidelines. Update the EMHSLU to recommend Amoxicillin to community level health care providers (VHT). • Incorporate amoxicillin supply to ICCM into the national supply chain through: (1) Support to MOH's on-‐going quantification effort of community-‐level demand for ORS and Zinc, including an assessment of the additional procurement cost for NMS; (2) quantification of ICCM consumption vs. facility consumption; (3) develop long term ICCM sustainability guidelines; (4) support facility-‐based VHT quality improvement collaborative meeting; (5) support the MoH in the roll out ICCM sanctioned VHT to other district, with a view to
Page 2 and 3: 1. BACKGROUND ...................
Page 4 and 5: 1. BACKGROUND 1.1 Introduction The
Page 6 and 7: RMNCH services and commodities
Page 8 and 9: 1.3 Process of development of
Page 10 and 11: integrated. There will be an i
Page 12 and 13: Product development/ market shap
Page 15: community level. However the po
Page 20 and 21: Specific issues identified Provid
Page 22 and 23: A parallel step will be to im
Page 24 and 25: inefficiencies and sustainability
Page 28 and 29: progressively achieve national c
Page 30: REFERENCES 1. Annual Health Secto

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EVERY WOMEN EVERY CHILD UN COMMISSION ON LIFE-âSAVING