Pneumonia Case Management Practices in Pakistan
Condition: Pneumonia; Childhood Pneumonia; Infectious Disease; Acute Respiratory Infection
MeSH terms: Pneumonia; Communicable Diseases; Infections; Respiratory Tract Infections
Study type: Observational

Summary: 
      Pneumonia in Pakistan continues to be the leading killer of children under five. Although
      various national and provincial programs have tried to tackle this but they have not been
      able to achieve the desired outcomes. Additionally, there has been limited in depth
      evaluation of the practices of pneumonia management at various levels of the community. The
      investigators, therefore, aim to establish an understanding of pneumonia case management at
      three levels of healthcare - community, first level care facility and practitioner level.
      This will be conducted through observations of pneumonia case managements practices of
      healthcare providers at these three levels across the country by simulated patients.
      Observation checklists will be developed incorporating settings and behaviors. Observation
      sites will be randomly selected with 32 observations made in each province. The results of
      this study will yield the ground reality of pneumonia case management in Pakistan. Based on
      the results of this study, strategies can be devised to improve case management within the
      community with models of regular monitoring and supervision.
    

Detailed description: 
      Despite the availability of standard pneumonia management guidelines and multiple global
      efforts, pneumonia continues to be the leading killer of children under five, accounting to
      around 17% of the total under five deaths globally. It has been estimated that annually there
      are around 120 million episodes of pneumonia among children with around 14 million
      progressing to severe episodes. Out of these cases, close to 1.3 million children die with
      81% of these deaths occurring in children under 2 years of age. Fifty two percent of these
      deaths occur in the Sub-Saharan region and South Asia with main contributions from India,
      Nigeria, Congo, Pakistan and Afghanistan. In Pakistan, pneumonia contributes to 16% of
      under-five mortality in the country having a well-defined yet poorly functional healthcare
      system.

      Healthcare in Pakistan is provided through two sectors; public and private. The public sector
      includes community health workers, referred to as Lady Health Workers (LHWs) working under
      the National Program for Family planning and Primary Health Care. It also includes the First
      Level Care Facilities referred to as Basic Health Units (BHUs) and Rural Health Centres
      (RHCs) and district/tertiary care hospitals. The private sector includes the private clinic
      and private hospitals. The public sector provides healthcare free of cost or with minimal
      charges whereas the private sector is expensive as patients spend out-of-pocket for health
      service in this sector. This accounts to the wide difference of quality of care across both
      the sectors as the public sector is not funded adequately by the government to provide high
      quality services, due to only 2% of the Gross Domestic Product (GDP) assigned to healthcare.
      Irrespective of the public and private sector, case management of pneumonia in children under
      five is supposed to be followed uniformly across all sectors as training of the healthcare
      providers is standard across all cadres of care under various programs in the country.
      Despite that fact, the mortality and morbidity rate due to pneumonia in children under five
      remains unchanged in the country.

      World Health Organization (WHO) and United Nations International Children's Emergency Fund
      (UNICEF) have developed multiple action/ intervention plans to curb pneumonia related
      morbidity and mortality in children under five and based on those plans Pakistan has launched
      multiple national programs. These programs include the National Acute Respiratory Illness
      (ARI) control program which was launched in 1989 with the main objectives of reducing
      severity and mortality due to pneumonia and rationalize the use of antimicrobials and other
      drugs for treatment of ARI. It was supported by WHO, UNICEF and United States Agency for
      International Development (USAID). While the program was ongoing, in 1990, in a National
      workshop on policy related research action plan, organized by the Ministry of Health, the
      Ministry of Planning and Development and the Aga Khan University (AKU), ARI was ranked sixth
      of fifteen priority areas for national policy-linked research. The National ARI Control
      program continued but WHO soon realized that this disease centric narrow approach has not
      been able to achieve its desired objectives. Therefore, it developed a more integrated
      approach and launched it globally as Integrated Management of Childhood Illnesses (IMCI)
      launched in Pakistan in 1998. The approach in IMCI focused on improving case management
      skills of health workers, strengthening the health system, and addressing family and
      community practices. Concerns were raised that this is yet another attempt to launch a child
      health intervention vertically. Duplicity was very much evident from the fact that ARI
      existed as an independent program and was also part of the IMCI package. Between 2004-2010, a
      USAID funded project called The Pakistan Initiative for Mothers and Newborns (PAIMAN) was
      undertaken which focused on improving the status of maternal and newborn health in 10
      districts (19% of the national population), which later expanded to 24 districts across the
      four provinces and Azad Jammu and Kashmir in Pakistan. ARI was an important component in that
      project. The national Maternal, Neonatal and Child Health program (MNCH) was then launched in
      2010 funded mainly by Development for International Development (DFID) implemented in 36
      districts and ended after 5 years. It was focused on strengthening of management and
      organization mechanism of healthcare delivery systems. Under all these programs, selected
      health care professionals, both community and facility based, were trained on WHO standard of
      ARI case management. Looking at the unchanged mortality statistics, there is a concern that
      these trainings might have failed to change the case management practices within the
      community. It is perhaps due to the fact that the monitoring and evaluation was not a strong
      point of these programs.

      There is limited data within Pakistan which reflects the status of the quality of current
      pneumonia case management practices throughout the three tiered health system (primary health
      facilities, secondary care hospitals, and tertiary care hospitals) as well as the private
      sector. There are a number of approaches which can be used to assess standard case management
      including recall based patient surveys, questionnaire surveys of knowledge,
      prescription/chart analysis and use of disguised patients to assess actual practice. A
      disguised patient is one who although suffers from a particular disease but acts as a
      disguised observer. Considering the use of disguised patients provides an actual picture of
      practice, therefore, it has been used extensively most recently. This process provides an
      assessment of the practitioners' knowledge of appropriate care and the actual care delivered,
      i.e., adherence to standard treatment guidelines. Such an approach in Pakistan can identify
      current pneumonia case management practices across the country because to-date no such study
      has been conducted in this field. The results of this study can help in informing design of
      future policies and interventions that can in turn assist in reducing pneumonia related
      morbidity and mortality.

      Methodology:

      This will be a qualitative study which will be conducted through participant observations
      over a period of 13 months across randomly selected sites in four provinces of Pakistan in
      addition to the federal capital. The provinces are Baluchistan, Khyber Pakhtunkhuwah (KPK),
      Punjab and Sindh.

      After obtaining ethical clearance, an observation tool will be developed based on standard
      WHO guidelines and input from field experts. This tool will be pretested upon finalization.
      At the same time an advisory committee will also be formulated composed of expert
      pediatricians and public health professionals who will provide their input into the
      implementation protocol and the tool. Once the tool is finalized training will be conducted
      on the tool and then observations will be conducted.

      Observation Sites:

      Observations sites will be randomly selected from each of the four provinces and the capital
      through our specialized sampling software. Upon site selection, observations will be made
      across the following levels of healthcare: community level, first level care facility (FLCF)
      and practitioner level both in the public and private sector. The community level
      observations will include observation of the pneumonia case management by the Lady Health
      Workers (LHWs). LHWs are the primary care givers at the community level who cover around 60%
      of Pakistan. Their basic duties include education, counseling and basic management of the
      common maternal and child ailments. Each LHW covers around 100-120 household and visits each
      household once a month. The observations will be made either at the health house of the LHW
      or she will be requested to visit the household of the disguised patient.

      The FLCF level will include observations made at the primary health care facilities which are
      the Basic Health Units (BHUs) and Rural Health Centres (RHCs). A basic health unit is located
      within a union council which is the smallest administrative unit in the Pakistani
      administrative system. Each basic health unit covers a catchment area of 25,000 households.
      Pakistan has around 5,290 Basic Health Units (BHUs) although not all are functional. Services
      provided at BHU are promotive, preventive, curative and referral. LHWs refer patients usually
      to BHUs. RHCs provide in-patient service as compared to BHUs. They usually have 10-20 beds
      and cover a catchment area of 100,000 people. The RHC provides promotive, preventive,
      curative, diagnostics and referral services apart from the in-patient services. It also
      provides clinical, logistical and managerial support to the BHUs, LHWs, and dispensaries that
      fall within its geographical limits. RHC also provides medico-legal, basic surgical, dental
      and ambulance services. There are around 552 RHCs in Pakistan.

      The practitioner level observations will include those of practitioners at both the private
      and public sector. The public sector will include observations made in outpatient departments
      of selected tertiary care hospitals across the study sites. Observations made at the private
      practitioner level will include selected solitary private clinics or clinics within private
      hospitals. The community and FLCF level will represent practices within the rural community
      and the practitioner level will represent practices within the semi urban/urban communities.

      Data Collectors:

      A team of data collectors, who will be healthcare professionals, will be trained on
      appropriate administration of the observation tool upon recruitment. The training will also
      include an introduction to pneumonia, its signs and symptoms, diagnosis and management
      according to WHO guidelines. A 3 day interactive training workshop will be conducted whereby
      mock excesses will also be conducted. A total of three training will be conducted whereby
      data collectors from Islamabad (capital), Punjab and KPK will have one training as their
      participants can be managed to be brought in one location due to close proximity. Sindh and
      Baluchistan participants will have two separate trainings.

      Recruitment of Patients' Caregiver and Conduction of Observations:

      Each data collector will be provided a pre-defined list of addresses whereby the observations
      will be made. He/she will go to the location and will search the nearby community for cases
      of pneumonia in children under five. Once the cases have been identified, their caregivers
      will be sought. These caregivers are the primary individuals providing direct care to the
      child. Usually, these are the mothers, fathers, grandmothers or guardians of the child. They
      will explained the purpose of the study and will be requested to participate in the study to
      accompany the data collector who will be disguised as a relative/friend of the caregiver, to
      the health facilities and upon agreement will sign a consent form. This means that they will
      disguise as an acquaintance of the data collector who will take them to the healthcare
      professional to be observed. They will take the ill child along, give the history of that
      child to the healthcare professional and answer any relevant questions which will be asked by
      him/her and get the child examined and treated. In the meantime, the data collector will make
      the relevant observations based on the observation tool which will be filled after the visit.
      The data collector will not reveal that he/she is a healthcare professional. Additionally,
      the data collector will also take an audio recorder along to record the entire conversation
      which will help in filling up the observation tool later and also validate the visit. Once
      the visit is completed, the data collector will take the caregiver back to their premises and
      fill up the observation tool in tablets within one hour of the visit. Electronic Case
      Recruitment Forms (eCRFs) will be used for improved data quality, avoidance of manual data
      entry errors and confidentiality etc.
    

Intervention name(s): Pneumonia Case Management Practices
Intervention type(s): Other
Intervention description(s): Standard practices of pneumonia case management at three levels of health care; community level, first level care facility and practitioner level, across Pakistan.
Observational model: Case-Only
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        Two data collectors per province will be recruited to make the observations making a total
        of 10 data collectors for all the locations. Additionally, one caregiver per observation
        will be recruited by the data collectors to accompany them. Meaning 160 caregivers will be
        recruited. This is to avoid inconvenience to the caregiver and their affected under five
        children. In case, a community is encountered whereby the cases of pneumonia are very few,
        then the same caregiver will be accompanied for observation of an LHW, BHU and RHC of that
        locality as these facilities are closely located. If despite this practice, number of
        observations are not achievable per site than an additional site will be provided to the
        data collector to visit.
      
Keywords: Childhood pneumonia; acute respiratory illness; Pakistan