Every breath counts in Nigeria: A coalition to accelerate reductions in child pneumonia deaths

Abstract

Pneumonia, the leading infectious killer of children under five, has been called a “forgotten killer,” “a neglected tragedy,” and a “global cause without champions.”1, 2 Despite causing 800 000 child deaths, more than HIV/AIDS, tuberculosis and malaria combined, pneumonia has never attracted the levels of support commensurate with its burden.3 Less than 5% of international Development Assistance for Health and just 3% of all infectious disease research spending, are allocated to pneumonia.4 While the Global Action Plan for Diarrhoea and Pneumonia (GAPPD)5 launched by World Health Organization and UNICEF in 2013 did set a global target of three child pneumonia deaths per 1000 live births by 2025, no government had developed a national strategy to achieve this target by 2019.a The lack of funding and planning have contributed to slow progress meeting the target and just two countries—Bangladesh and Indonesia—of the 20 with more than 10 000 annual child pneumonia deaths are on track to achieve the GAPPD pneumonia target.6 At current rates of progress, an estimated 6.3 million children will die from pneumonia by 2030 and many low- and middle-income countries (LMICs) will fail to achieve the sustainable development goal for child survival. The solution is not another vertical program channeling billions of dollars to tackle a single disease. There would be little appetite from national governments or the global health and development community for such a mechanism, which might undermine efforts to expand the reach of integrated community case management (iCCM) and integrated management of childhood illness (IMCI) and strengthen primary health care services to deliver Universal Health Coverage (UHC). Experience suggests that further reductions in child mortality in LMICs will require approaches that are sensitive to the complex patterns of comorbidity between pneumonia, diarrhea, malaria and malnutrition, and cognizant of the rising challenges of rapid urbanization, vaccine hesitancy, air pollution, and the double burden of under and overnutrition. The case for harnessing existing mechanisms such as Gavi, the Global Fund, Unitaid, and the Global Financing Facility to better integrate vaccine delivery, nutrition, and community case management is increasingly compelling, and much more work is needed to align the efforts of international agencies engaged in child survival in the high-burden countries.7 The Every Breath Counts Coalition (EBCC; https://stoppneumonia.org/) was officially launched in November 2017 to provide a platform for governments and international health agencies to work together to achieve the GAPPD target. In an acknowledgment of the progress achieved by the Global Fund and Gavi, the 40 member EBCC is a public-private partnership with representation from UN agencies, nongovernmental organizations (NGOs), private foundations, pharmaceutical and medical technology companies, and universities. Each member has made a written commitment to support government efforts to accelerate reductions in child pneumonia deaths according to their capabilities along with the prevention, protection, diagnosis, and treatment continuum. EBCC works with governments to develop data-based pneumonia control strategies, delivered as part of national primary health care strengthening and UHC efforts. The EBCC has prioritized support to four large “transnational” clusters with large populations of children at heightened risk of death from pneumonia including, (a) Chad, Nigeria, Niger, and Mali, (b) Democratic Republic of Congo and Angola, (c) Ethiopia and Somalia, and (d) Pakistan and Afghanistan, the ambition of which is to support the development of bespoke pneumonia control strategies in each country. At the global level, three EBCC teams drive progress towards specific childhood pneumonia “global public goods” including: The development of routine indicators to measure access to pneumonia diagnosis and treatment; a set of agreed research priorities; and robust advocacy and communications activities. As Nigeria has the largest population of children at greatest risk of death from pneumonia, the EBCC supported the Nigerian Federal Ministry of Health (FMoH) to develop a pneumonia control strategy between January 2019 and 2020. Coalition members including USAID, the Nigerian offices of Dalberg, Save the Children, UNICEF, and the Clinton Health Access Initiative (CHAI) joined forces to support the process. To better understand the barriers preventing faster progress on reducing child pneumonia deaths in Nigeria, the Family Health Department within the FMoH invited 75 participants to a strategy workshop in Abuja in January 2019. Following this workshop, approximately 40 interviews with national and global stakeholders, supplemented by desk research and analysis of state-level policies and data on the burden of pneumonia deaths, were conducted by the strategy firm Dalberg on behalf of the FMoH. By early March 2019, the FMoH and the EBCC had developed a draft pneumonia control strategy, and the FMoH invited 30 partners to meet in Abuja in April 2019 to review the strategy and align the contents with the RMNCAH+N Strategy. EBCC and the FMoH then worked together to develop a more detailed implementation plan and an estimation of the financial resources needed to implement the strategy. Less than 7 months after the process began, a final workshop to validate the strategy took place in Abuja in July 2019. In October 2019, the Minister of Health officially approved the strategy and the strategy was officially launched in Nigeria on January 2020. This strategy development process generated several key lessons. The pneumonia control strategy development process elevated the status of childhood pneumonia as a key public health challenge in Nigeria. Bringing together a range of public (eg, Federal and State Ministries of Health and donor government missions), private (eg, manufacturers of vaccines, medical devices, and antibiotics), faith-based organizations, and civil society actors demonstrated an appetite for a greater focus on pneumonia and drew attention to the gaps and barriers in pneumonia control that were impeding progress to Nigeria's child survival target. Despite many competing priorities in health, stakeholders involved in the process became champions for pneumonia control. Two NGOs, Save the Children and CHAI even decided to integrate parts of the pneumonia control strategy into their own newborn and child health programming. The pneumonia control strategy development process also showed that it is possible to focus on a specific cause of child death, while promoting integrated case management of childhood illnesses at community and facility levels (ie, iCCM and IMCI). By emphasizing that pneumonia should be accorded a level of attention commensurate with its disease burden, the FMoH and EBCC were able to reposition and prioritize pneumonia as a major killer, deserving of at least the same levels of investment as other leading but much better resourced killers (eg, malaria). The process to develop the pneumonia control strategy enhanced cross-sectoral and interministerial collaboration across all levels of government in Nigeria. Effective pneumonia control depends on the coordinated actions of different federal, state, and local government agencies to prevent, diagnose, and treat pneumonia at all levels of the health care system. The Nigerian FMoH had to work closely with the Agriculture, Energy, and Environment Ministries to prevent pneumonia by improving vaccination, nutrition, and clean air. In addition, the FMoH must find ways to influence State and Local Government health actors to improve the diagnosis and treatment of childhood pneumonia in primary health care and hospital services, as these are decentralized responsibilities. The FMoH and EBCC were able to bring these various government actors together for the first time to talk about pneumonia control and offer the support of private and nonprofit sector partners. Lastly, and critically, the experience in Nigeria highlights the importance of taking a data-driven approach that puts the most vulnerable populations of children first. While it is still challenging to map child pneumonia deaths at national and subnational levels, data are improving rapidly and governments have new tools to identify childhood pneumonia “hotspots” where deaths concentrate.8 In Nigeria, the subnational child pneumonia maps released by the Institute for Health Metrics and Evaluation in 2019 revealed “hotspots” in several northern states. Targeting pneumonia control efforts to these children represents the most cost-effective path to reduce pneumonia deaths and achieve the GAPPD target. The EBCC is committed to sharing these new tools with governments so that they can help direct scarce resources in ways that maximize the number of child pneumonia deaths prevented. These maps not only enable governments to prioritize the most vulnerable children but also to require their international health and development partners to do the same. Nigeria is pioneering a new approach to achieving the GAPPD target. Its pneumonia control strategy will need to be monitored and evaluated over the next 5 years to assess results, to ensure that partners are held accountable for delivering on their commitments and to capture learnings that can inform other governments. If successful, the Nigerian pneumonia control strategy could become a blueprint for other countries struggling with heavy burdens of child pneumonia deaths to achieve the GAPPD target and strengthen integrated newborn and child health policies and programs.