11 November 2011

Pakistan's Lady Health Workers: Treating Severe Pneumonia in Children on the Front Lines

Often thought of as a disease of the elderly, pneumonia is the leading killer of children under the age of five. It causes twice as many deaths as malaria and seven times more than AIDS. In many communities accessing care can be a challenge. Of the 1.4 million annual pneumonia deaths for children under 5, 99% occur in developing countries. Many of the most effective interventions include the use of Community Health Workers.

Tomorrow’s World Pneumonia Day celebration means that flurry of new studies are being released. Today, the Lancet has published a groundbreaking study on how Pakistan’s “Lady Health Workers” (LHWs) are more effective in ensuring the recovery of children stricken with pneumonia as opposed to those who are referred to health facilities.

Lady Health Workers in Pakistan reach the homes of roughly 150-200 families every month. Chosen through the community, they only need a few months of training before they are ready to begin serving their communities. While they work, the LHWs are provided ongoing supervision and basic supplies.

Present WHO guidelines do not now allow for children to be cared for by community health workers when pneumonia is defined as severe. There is evidence that community health workers are effective when treating children before this point, but research had not been conducted at the point of the pneumonia being considered severe. Presently, only 50% of children with pneumonia are given antibiotics.

Save the Children, USAID and the WHO have collaborated to test if community health workers can be effective in treating sever pneumonia in children. The study consisted of 3,211 children with severe pneumonia in the Haripur district of Pakistan. Designed as a randomized control trial, the children were split into two groups. The treatment group were provided oral amoxicillin by the LHWs for five days. Prior, the Lady Health Workers had received training on how to treat the children. The control group followed stand procedure by administering a dose of the oral co-trimoxazole and making a referral to a local health facility.

The researchers found that the children in the treatment group were more likely to receive proper care. After five days, 18% of children referred to a facility were still sick, compared to 9% of those treated by LHWs. This study in Pakistan goes one step further. “Not only do oral antibiotics work, but they do when given at home just as well as at a clinic,” said Dr. Elizabeth Mason, WHO Director of Maternal, Newborn, Child and Adolescent Health on Thursday. “Children can be treated earlier and this will make treatment more accessible to poor and isolated communities. Governments can make the best of their limited resources and, most importantly, save more lives.”

The authors of the study conclude by urging the WHO to change its recommendation in regards to the treatment of children under five suffering from severe pneumonia. They argue that the rigor of the study sufficiently proves their point and finish by saying, “Based on previous results of reduced mortality rates with community case management, we postulate that it will contribute further to a reduction in the number of pneumonia deaths and accelerate the process of achieving MDG 4.”

With a known solution, the challenge will be ensuring the proper implementation. The world is short by 3 to 4 million doctors, midwives and nurses. To fill this gap, community health workers are used in many countries, but they are employed both formally and informally. The formal group has the appropriate training and support, like the LHWs in Pakistan, and can dispense antibiotics that will reach more children with pneumonia.

“It is harder when they are volunteers and the movement in and out of the sector is quite considerable,” says Dr Mason. “Having regular figures of this group is quite difficult. Meaning that the WHO has been unable to make recommendations in regards them.” She continued saying, “Since they are not formally included in the system, informal workers can pose a problem in terms of care. We would argue that they are a part of the system, and advocate for that to ensure they get the necessary support and deliver quality care.”