Promoting the Integrated Community Case Management of Pneumonia in Children - Management Assignment Help

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Promoting the integrated community case management of pneumonia in children under 5 years in Nigeria through the proprietary and patent medicine vendors: a cost-efectiveness analysis Charles E. Okafor1,2* , Obinna I. Ekwunife3 and Sabina O. Nduaguba4,5 Abstract Background: While evidence-based recommendations for the management pneumonia in under-5-year-olds at the community level with amoxicillin dispersible tablets (DT) were made by the World Health Organisation, initiatives to promote the integrated community case management (iCCM) of pneumonia through the proprietary and patent medicine vendors (PPMVs) have been poorly utilized in Nigeria, possibly due to low fnancial support and perceived beneft. This study provides costs, benefts and cost-efectiveness estimates and implications of promoting the iCCM through the PPMVs’ education and support. The outcome of this study will help inform healthcare decisions in Nigeria. Methods: This study was a cost-efectiveness analysis using a simulation-based Markov model. Two approaches were compared, the ‘no promotion’ and the ‘promotion’ scenarios. The health outcomes include disability-adjusted life years averted and severe pneumonia hospitalisation cost averted. The costs were expressed in 2019 US dollars. Results: The promotion of iCCM through the PPMVs was very cost efective with an incremental cost-efectiveness ratio of US$143.77 (95% CI US$137.42–150.50)/DALY averted. The promotion will prevent 28,359 cases of severe pneumonia hospitalisation with an estimated healthcare cost of US$390,578. It will also avert 900 deaths in a year. Conclusion: Promoting the iCCM for the treatment of pneumonia in children under 5 years through education and support of the PPMVs holds promise to harness the benefts of amoxicillin DT and provide a high return on investment. A nationwide promotion exercise should be considered especially in remote areas of the country. Keywords: Proprietary and patent medicine vendors, Amoxicillin dispersible tablets, Beneft, Education, Support, Nigeria © The Author(s) 2021. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativeco mmons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/ zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Background Te World Health Organisation (WHO) recommends the use of oral amoxicillin dispersible tablet (DT) as the frst-line agent in the management of uncomplicated cases of pneumonia in children under 5 years at the community level and parenteral penicillin and gentamicin as frst-line in severe cases [1], but implementation in Nigeria remains poor especially in rural communities. Te Nigerian Ministry of Health in collaboration with the Maternal and Child Survival Program (MCSP), and the WHO have implemented the Saving One Million Lives project [2]. Tis project aims to support community case management of illness such as pneumonia, malaria Open Access Cost Effectiveness and Resource Allocation *Correspondence: charles.okafor@grifthuni.edu.au 1 Centre for Applied Health Economics, School of Medicine, Grifth University, 170 Kessels Road, Nathan, QLD 4111, Australia Full list of author information is available at the end of the article Okafor et al. Cost Ef Resour Alloc (2021) 19:12 Page 2 of 10 and diarrhoea as a strategy to improve treatment access and coverage especially for children living in rural areas [3]. Te integrated community case management (iCCM) strategy enables assessment, classifcation, treatment and referral of pneumonia, diarrhoea and malaria cases [4]. Te United Nations agencies and other donor agencies have supported the implementation of the iCCM in Nigeria [2]. Following the implementation of the national iCCM guidelines in the year 2013, the occurrence of childhood illness has reduced, and management of pneumonia improved but implementation remains poor [2]. A plausible reason for the poor result was the initial focus of iCCM support on community health workers and less focus on the proprietary and patent medicine vendors (PPMVs) who are ubiquitous in the communities. Te PPMVs are drug vendors without formal training in pharmacy and are issued a licence by the Pharmacist Council of Nigeria (PCN) to retail non-prescription medications. Te iCCM strategy has led to the removal of amoxicillin DT from the prescription-only medicine list to enable the PPMVs to have access to the drug for the treatment of non-severe childhood pneumonia at the community level [5]. In Nigeria, this decision was also supported by the fact that majority of the populace in rural areas visit PPMVs for medical advice, diagnosis, medications and general health management due to their low service cost and accessibility [6, 7]. A study in Uganda has also shown that the PPMVs are indispensable at the rural communities [8]. Te study showed that promoting iCCM for uncomplicated pneumonia through the support of PPMVs has the potential to reduce the disease burden [8]. Te coalition promoting the iCCM foresaw a problem of abuse and increased resistance to amoxicillin DT due to the possibility of irrational dispensing. Tis foreseen challenge called for the need to educate PPMVs (due to their low medical knowledge) who will sell the amoxicillin DT to patients. Te training of PPMVs involves basic education about signs of pneumonia including danger signs, use of respiratory rate timers, how to dose the drug and when to refer patients in complicated cases to healthcare facilities. Te MCSP in collaboration with the United States Agency for International Development (USAID) conducted an education outreach in the year 2017 in four local government areas (Idah, Okehi, Izzi and Ohaozara) of two states in Nigeria (Kogi state and Ebonyi state) to test the feasibility of promoting the iCCM through the PPPVs [9]. Te training held also included education on management of diarrhoea and malaria at the community level and when to refer patients to healthcare facilities [9]. In addition to supporting one of the training in Kogi state, Nemel Pharmaceuticals Limited, an indigenous pharmaceutical company of Nigeria in the year 2018 sponsored the iCCM training through the PCN in few local government areas of Enugu state and the Federal Capital Territory of Nigeria [9]. Te outreach reported over 90% turn out of the expected trainees. Following the successful implementation of the training, the PPMVs national executive committee demanded promotion in other PPMVs locations. However, the promotion was decelerated possibly due to fund limitation and low perceived beneft [9]. Tis lacuna calls for evidence-based analysis of its beneft to encourage government and donor agencies buy-in. Tis problem has informed the need for health economic evaluation of the promotion exercise to assess whether scale-up of education and support of the PPMVs in the practice of iCCM for under-fve pneumonia management will be benefcial to Nigeria. Tis study, therefore, aimed to evaluate the cost-efectiveness of promoting iCCM for the management of pneumonia for children under 5 years in Nigeria through education and support of the PPMVs. Methods Study setting and sample size Te PPMV shops and community pharmacies are the major providers of health service at the community level for non-severe health conditions in Nigeria. Te survey by the MCSP and the USAID showed that care-seeking at PPMVs shops for fever, diarrhoea, cough or pneumonia was about 40% in Nigeria and was used in this study [9]. Based on the care-seeking, the population used in the study was 40% of 34.6 million Nigerian children under 5  years based on the 2019 population report and the care-seeking at PPMV shops [10]. Tis population was used as the starting population in the model (well state) but at risk of having childhood pneumonia.

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