Background The Acute Respiratory Infections (ARI) programme in Malawi aims to reduce pneumonia deaths among children under-five years of age. Pneumonia standard case management is implemented through the Child Lung Health Project. After 24 months a significantly reduced pneumonia death rate has been observed throughout the districts where the programme has been implemented, however, the reduction has varied from district to district. In some districts the pneumonia case fatality rate was reduced by 60%, while in others it was less than 10%.
Aim of the study: Was to investigate reasons for pneumonia case fatality rate variations in the different district hospitals in Malawi.
Methods: This was a retrospective study of all children less than five years admitted in the district hospitals with a cough and difficult breathing from 1st July 2002 until 30th June 2003. A total of 6480 children were admitted. Of the 6480 children, 6202 (95.7%) met the study criteria. Out of 6202 children, 523 children died (8.7% CFR). We also conducted structured interviews with district health management team members on health service delivery at the district hospitals. Logistic regression was applied to measure the effect of the patient related factors and examine the health service delivery factors on pneumonia deaths with adjustement for potential confounders. Adjustement for age and sex was made to separate the effect of the study factors on pneumonia deaths.
Results: We observed that case fatality rate was twice as high in Thyolo (14.1%) and in Machinga (14.6%) compared with Dedza (7.3%). In Mulanje the case fatality rate was lowest (4.9%) among the ten districts studied. The risk of death changed little after adjustment for age and sex. However, after adjusting for severity of disease at admission, the increased risk in Thyolo and the decreases risk in Mulanje were attenuated and no longer significantly different from Dedza. This implies that there were more children with very severe pneumonia admitted in Thyolo. On the other hand, the increased risk in Machinga persisted and increased risk was also found in Salima. After adjusting for missing doses of antibiotics in addition to age, sex and severity of disease, the risk of death in Machinga was almost twice that of Dedza, while in Ntcheu, Mulanje, Kasungu and Salima it was lower than Dedza. This implies missing doses was the main problem. Possible causes of variations in pneumonia case fatality rate across districts in this study include the admission of more severely ill children and missing doses of antibiotics.
Conclusion: The findings contribute to the hypothesis that pneumonia case fatality rate variations are influenced by district service delivery factors. The results suggest some evidence for improving within-hospital management to reduce pneumonia deaths. If the children could receive the prescribed doses of antibiotics, the outcome may improve.