Date Published: November 10, 2009
Publisher: Public Library of Science
Author(s): Penelope Marjorie Enarson, Robert Gie, Donald A. Enarson, Charles Mwansambo
Abstract: Penelope Enarson and colleagues describe the development, scale-up, and achievements of a national pneumonia program in Malawi, which is based on a successful anti-tuberculosis service delivery model.
Partial Text: The reduction of child mortality by two-thirds from its 1990 level by 2015—the fourth United Nations Millennium Development Goal—is a major challenge. Pneumonia accounts for much (≥20%) of this mortality in poor countries, but standard case management (SCM) of pneumonia  has the potential to reduce overall child mortality. A recent meta-analysis estimated that SCM of pneumonia could reduce overall mortality in neonates, infants under 1 y old, and children aged 0–4 y, respectively, by 27%, 20%, and 24%, and pneumonia-specific mortality by 42%, 36%, and 36% in the same age groups .
The International Union Against Tuberculosis and Lung Disease (The Union) previously pioneered an effective delivery model for antituberculosis services  for patients in poor countries. The approach used in this framework, which is one of the most cost-effective health interventions  devised so far, was incorporated into the WHO Stop TB Strategy and, by 2005, it had been successfully introduced into 190 countries . Its principles include political commitment, standardized diagnosis and treatment, training, logistics, recording and reporting, supervision, and evaluation of services.
In 1999 the Government of Malawi asked The Union to assist it in the development and implementation of a Child Lung Health Programme (CLHP) to manage children under 5 y old hospitalized with severe/very severe pneumonia. The government identified the following problems: (1) inadequate health-worker skills in district hospitals; (2) inadequate supplies of antibiotics and equipment to administer oxygen therapy; (3) deficient use of strategic information.
The major challenge facing the implementation of the CLHP in Malawi has been a shortage of health care workers. In particular, the attrition rate of trained workers has been high because of recruitment to the private sector, transfer of trained staff to other government hospitals, and deaths from HIV/AIDS. To address this problem, regular in-service and on-the-job training has been introduced and participation in the annual CLHP training course extended. The MOH has also increased the intake to nurses’ training institutes and restarted the Medical Assistant training programme.
The implementation of the CLHP in Malawi demonstrates the feasibility and effectiveness of a model programme based on the principles of the successful model for tuberculosis control to reduce case fatality in children hospitalized for pneumonia within first-level referral hospitals. The experience shows that while external funding is required to introduce the CLHP, the other key elements of the model are also necessary. Although it has not been possible to compare this approach, which has a substantial vertical component, with a locally integrated approach, the experience in Malawi suggests that this model could help the world achieve Millennium Development Goal 4.