health system considerations for community-based implementation of automated respiratory counters to identify childhood pneumonia in 5 regions of ethiopia: a qualitative study

Background  in ethiopia, childhood pneumonia is diagnosed in primary healthcare settings by measuring respiratory rate (rr) along with the presence of cough, chest indrawing, difficulty breathing, and fast breathing. our aim was to identify health system-level lessons from implementing two automated rr counters, children’s automated respiration monitor (charm) by phillips® and rad-g by masimo®, to provide considerations for integrating such devices into child health programmes and health systems. this study was part of an initiative called the acute respiratory infection diagnostic aids (arida).methods  key informant interviews (kiis) were conducted with 57 participants (health workers in communities and facilities, trainers of health workers, district management, and key decision-makers) in five regions of ethiopia. data were analyzed in atlas.ti using thematic content analysis and themes were categorized using the tanahashi bottleneck analysis.results  all participants recommended scaling up the arida initiative nationally as part of integrated management of newborn and childhood illness (imnci) in primary healthcare. health workers perceived the devices as: time saving, acceptable by parents and children, and facilitating diagnosis and referrals. health workers perceived an increased demand for services and reduced numbers of sick children not seeking care. participants recommended increasing the number of devices distributed and health workers trained. strengthening drug supply chains, improving oxygen gas availability, and strengthening referral networks would maximize perceived benefits. while training improved knowledge, more supportive supervision, integration with current guidelines and more guidance related to community engagement was recommended.conclusion  automatic rr counters for the decentralized diagnosis of childhood pneumonia could have positive impact on improving the quality of diagnosis and management of pneumonia in children. however, the study has shown that a health system approach is required to ensure all steps along the pneumonia pathway are adequate, including drug and oxygen supply, community engagement, health worker training and support, and referral pathways.