According to WHO, pneumonia accounts for more than 20% of deaths among children under five years of age and is the number one killer of young children worldwide, responsible for more than 1.5 million childhood deaths each year. Pneumonia or ALRI includes bacterial pneumonia, bronchitis and bronchiolitis, but bacterial pneumonia is responsible for the majority (around 90%) of the deaths.

 

Effective case management is possible in resource-poor settings using simple clinical assessment strategy; antibiotics aimed at the common bacterial pathogens, such as pneumococcus, as well as effective management of hypoxia for the most severe cases. Implementation of case management therefore requires training, antibiotics and oxygen. The case management strategy has been shown to reduce the case fatality rate, as has accurate identification and effective management of hypoxia, and both strategies are highly cost-effective. Implementation of preventative strategies, such as effective vaccines against pertussis, measles, Hib and pneumococcus, also reduce the burden of child pneumonia, as would strategies that reduce child HIV prevalence.

 

Tuberculosis (TB) and HIV-related lung diseases, such as Pneumocystis pneumonia, are other important causes of acute pneumonia in infants in regions with a high pneumonia-related mortality and endemic for TB and HIV. Strategies to prevent and manage child pneumonia also have potential to reduce the burden of other important causes of child mortality, such as neonatal and childhood sepsis. Despite all of this, access to care and implementation of preventive and management strategies remain a challenge in the high burden settings.

The Child Lung Health Programme (CLHP) in Malawi

In 2000, Malawi had a case fatality rate (CFR) of 18.6% for children under 59 months of age, who were treated for pneumonia on an inpatient basis. The Malawi Child Lung Health Programme (CLHP) was launched that year with the objective of reducing this rate to 12.5%.

 

A successful pilot: 2000–2005

Within three years, the CLHP in Malawi had been implemented at the district hospital level in 24 of 25 districts. Following project implementation, there was a marked reduction in case fatality rates for severe and very severe pneumonia in children less than five years of age. As of December 2005, 63 months after the start of the project, the results far exceeded the original objective with the overall CFR falling to 8.4% – a reduction of 54.8%.

 

The CLHP's initial success was based on the World Health Organization (WHO) technical guidelines on inpatient management of the child with a serious infection; The Union's managerial model for delivery of health services; and funding from the Bill and Melinda Gates Foundation.

 

Key aspects of the programme were that it was incorporated into Malawi's existing structure for the organisation of health services; and it was implemented by hospital personnel already working on the control of acute respiratory infections (ARI) and the programme for integrated management of childhood illnesses (IMCI). Policies introduced by the CLHP were thus coordinated with those already in place in the health services. In addition, great emphasis was placed on coordinating with all health management systems as well as other players in the health services.

 

Extending the reach of the programme: 2006–2008

Between 2006 and 2008, the CLHP was expanded to incorporate a number of the Christian Health Association of Malawi (CHAM) hospitals, thanks to a three-year grant from the Scottish Government.

 

A sustainable programme: 2006 – the present

Based on the CLHP's successful results, The Ministry of Health of Malawi included it in the Essential Health Package (EHP), which is funded through the National Planning Sector Wide Approach (SWAp). It is one of the 11 interventions included in the EHP for "Management of Acute Respiratory Infections and related complications".