Sarah Ruteri*, aged 14 months, is a survivor. A few months ago, I saw her admitted to the pediatric ward of Lodwar hospital in northern Kenya’s drought-affected Turkana district. Suffering from severe pneumonia, Sarah was gasping for breath – and fighting for her life. Her tiny ribcage was convulsed by a losing struggle to get air into her lungs. Doctors told her mother to expect the worst. But with a combination of oxygen therapy and intravenous antibiotics, Sarah pulled through.
Others are not so lucky. Over half of the 25 children on the ward in Lodwar the day I visited had pneumonia. Three of them died within a week. All of them could have survived if their condition had been diagnosed and treated early enough.
The life and death struggles played out in Lodwar hospital are a microcosm of the world’s most neglected public health crisis – and a reminder of what is at stake in the drive to achieve universal health coverage.
If you conducted a straw poll among World Bank staff, asking them to name the biggest killers of children in poor countries, it’s a safe bet that diarrhea or malaria would claim the top spot. You’d get the same outcome in most non-government organizations (trust me: I’ve done the straw polling). In fact, pneumonia kills more children than any other infectious disease – and more than diarrhea and malaria combined. The most recent estimates put the body count at around 900,000 annually. That represents 16 percent of child deaths, with the majority taking place among children aged less than 2 years old.
To make matters worse, pneumonia deaths are falling more slowly than other major killers. On current trends, if nothing changes, there will still be 735,000 deaths in 2030 - the target date for achieving the Sustainable Development Goal ambition of ‘ending preventable child deaths’.
Almost all pneumonia deaths are preventable. Effective pneumococcal conjugate vaccines (PCVs) can immunize children against the major bacterial strains. When pneumonia strikes, most cases can be successfully treated with simple antibiotics. The cost: around $0.40 cents. More complex cases, like those on the ward in Lodwar, need oxygen treatment, higher-level antibiotics and treatment for associated conditions. The key to success is early and accurate diagnosis, linked to accessible primary care and an efficient referral system.
So why do so many children die of pneumonia? In short, because of a lethal interaction between inequality and health system failure. Save the Children addresses this in our recent report Fighting for Breath. Pneumonia is the ultimate disease of poverty. The children most at risk are poor, with immune systems comprised by malnutrition and other factors. These children are the least likely to have access to effective care. And for all the progress in extending PCV coverage through Gavi (the Vaccine Alliance), there are still 170 million children not vaccinated against pneumonia, particularly in middle-income countries.
Bending the curve on pneumonia deaths will require some big policy shifts.
To start, national governments in high burden areas need to prioritise prevention and treatment. We are calling on these governments to adopt Pneumonia Action Plans that identify the children at greatest risk, strengthen provision through Integrated Community Case Management, and ensure that primary health facilities are accessible and equipped to treat the disease. These plans should not be seen as ‘vertical interventions’, but as building blocks for universal health coverage. There is no substitute for accessible primary health care in combating pneumonia. Yet over 800 million people in developing countries are spending more than 10 percent of their incomes on health – and 100 million are driven into poverty by health fees. Changing this picture will require an increase in public spending. We should all be calling for governments to spend at least 5% of GDP on health, allied to more equitable and efficient spending.
International action has a critical role to play. Gavi has helped to lower prices through guaranteed advance purchases. It has contributed to the immunisation of more than 47 million children. But more must be done. For instance, bonds and other instruments could be used to fund an increase in guaranteed purchases, subject to lower offer prices from manufacturers and to drive more suppliers into the market to reduce prices for the future.
The Global Financing Facility (GFF) has a distinctive role to play, too. It has a remit to close the financing gap for achieving the health SDGs by supporting country-led strategies. We actively support the case for replenishment of the Trust Fund. This is the type of innovative financing mechanism that can make a difference. Maximising the impact of the GFF will require that special attention is paid to the old problem of more aid being used to reduce domestic spending - and this issue is rightly at the heart of dialogue with governments. The GFF also needs to show results in promoting increased domestic resource allocation for childhood illnesses. In the context, it should be attaching more weight to pneumonia - not least because of the huge potential co- benefits for child and maternal health that will come with improved diagnostic and treatment capabilities.
Perhaps the biggest barrier to action on pneumonia to date has been the weakness of global partnership. Unlike malaria, and even diarrhea, this is a disease has lacked effective champions, nationally and globally. There are signs of change. The creation of the Every Breath Counts coalition, which brings together a coalition of partners from governments, UN agencies, the business community and NGOs could become a powerful catalyst for the policies needed to save lives.
It is time to raise the veil of indifference surrounding pneumonia. Delivering on the 2030 child survival pledge depends on it. So do the lives of children like Sarah Ruteri. We owe it to them to join the fight for their lives.