Reducing pneumonia and diarrhea mortality of children under 5 in Marcala, La Paz, Honduras

 

Problem: 

In 2008, 17 children under 5 in the Marcala district died from diarrhea and pneumonia. The local maternal clinic (CMI) had evolved into an emergency room of sorts; however, the clinic staff had neither the time nor the funds to serve this population outside of their mandate. There was a significant need to improve referrals to other health clinics in the Marcala health network. The local quality improvement team proposed that trained community volunteers could administer a first dose of antibiotics or oral rehydration solution in the community, implement a referral system, improve the quality of care at the health centers, and provide follow up to all sick children within 48 hours.

Intervention: 

The La Paz collaborative implemented changes at both the community level and facility level. A major initiative in the collaborative was to reorganize the provision of care among the health units and clinics in the area so they could better work together and distribute caseloads. Staff from participating health units met at quarterly learning sessions to promote sharing and learning among the teams. Each meeting included health education presentations, knowledge sharing and feedback by participants, discussions of various units’ challenges and lessons learned, and presentations of regional surveillance data. The community committees also gathered every three to six months to share their experiences, led by the health facility staff.

Changes were also introduced at the health facilities serving the communities in the collaborative. Staff were given a review of how to use surveillance graphs to track pneumonia and diarrhea cases. Facilities developed pneumonia and diarrhea treatment flowcharts and introduced a triage protocol, as well as protocols for rehydration for 4+ hours and follow-up within 48 hours. When a sick child arrives at the clinic through the referral system, he or she receives priority treatment. The facilities tracked community referrals by registering them in a notebook. Clinic health staff educated mothers of treated children about the causes of pneumonia and diarrhea at the time of their consults in order to promote prevention of the diseases in the community. Additionally, the facilities offered housing to children and their families in the maternity waiting home when these children needed further follow-up after care.
 
Community management committees were formed in 11 communities in the Marcala area. All members are responsible for finding and referring sick children. Members were trained in community integrated management childhood illness (IMCI), specifically the prevention of pneumonia and diarrhea, to recognize danger signs in children under 5, and how to provide initial treatment. The communities received stocks of oral rehydration solution and antibiotics from the clinics, which they administered to sick children in the community before the child was referred to the proper health center; they monitored supplies monthly to prevent stock-outs. The committees used cell phones to phone in referrals to health units to alert staff that a sick child would arrive and documented referrals in a community notebook. The Marcala health center staff regularly visited each community to analyze and supervise referrals. The communities monitored and re-supplied their medications monthly in order to prevent stock outs.
 
Results: 

The collaborative team developed and validated 7 indicators to measure treatment and referrals in the communities related to correct treatment and correct registration completion by the staff. The most striking outcome of the La Paz collaborative was a stark decrease in children’s pneumonia and diarrhea related mortality. At baseline, 17 children died in 2008 from pneumonia and diarrhea in the surveyed area. In 2009, the first year of the collaborative, this was reduced to four deaths. In 2010, there were five total deaths; however, a long rainy season caused a sharp rise in pneumonia incidence that year. Remarkably, the Marcala health units were still able to limit pneumonia- and diarrhea-associated mortality even while the number of pneumonia cases reached levels high above the designated “alarm” stage. These gains are illustrated in the attached graphs. Overall, the number of community referrals has doubled each month. With no community treatment at baseline, by the end of the collaborative, 100% of children with pneumonia or diarrhea received initial treatment in the community and a referral to a health unit. Although the teams emphasized the importance of follow-up care within 48 hours for children with pneumonia, in 2010, only 14% of children returned to the clinic for follow-up. However, in the community, about 73% of pneumonia patients received this care within 48 hours. The quality of care has improved during the project; at baseline, 35% of pneumonia patients received care according to evidence-based protocols; by the end of the project, this increased to 94%. Proper documentation in the clinics has improved from about 71% to 90% of patients, although this remains short of the 100% target.

Lessons: 

The successes in Marcala could not be achieved without the buy-in and participation of community members; while the involvement of health workers was important in achieving a reduction in pneumonia- and diarrhea-related mortality among children under 5, the participation of community members is critical. Administration of initial treatment in the communities proved successful, but it was difficult at times to maintain the supply of these drugs despite monthly supply monitoring by the committee members. If the clinics were stocked out of oral rehydration solution or antibiotics, the communities would not receive their supply; higher level coordination with the Ministry of Health might mitigate this issue. The collaborative prioritized its interventions in the communities with the highest mortality rates, which was a successful strategy. A challenge in the program was achieving follow-up within 48 hours for children with pneumonia. As only 14% of families returned to the clinic for care, the Marcala team utilized community committee members to provide follow-up, which helped reach many more children. Another challenge was securing enough funding to institutionalize training programs for the community committees. This training proved valuable as committee members were more knowledgeable about prevention and treatment of diarrhea and pneumonia and better able to address these issues in their communities. However, with a lack of funds, the collaborative could not provide additional trainings to new committee members or continued training throughout the collaborative, nor expand to other communities in the district. As this affects the sustainability of these gains in mortality reduction, it is important to ensure training funds will be available to incorporate new participants and communities throughout the collaborative. The program also was not able to provide incentives to community members; however, they were very motivated by the reductions in mortality they saw through their work. The collaborative did make funds available to cover the expenses for the health staff’s travel to communities as well as their overtime work on weekends, which motivated these workers to dedicate their time to the goals of the collaborative.

 

Countries: 
Report Author(s): 
Norma Aly & Malena Banegas
Organization(s): 
USAID Health Care Improvement Project/URC
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