Bangladesh has made significant progress in reduction of infant and child mortality rates in recent decades, two basic indicators of country’s socioeconomic condition and quality of life. But still, over 135,000 under five children die in Bangladesh (BDHS 2017). Reducing under-five mortality—in line with Sustainable Development Goal (SDG) 3.2—is therefore core to realising Bangladesh’s full economic and social potential.
To date, progress to address pneumonia—known as the “forgotten killer—has been insufficient. It poses significant burden on families, communities and the health system. In 1989-93 death due to pneumonia was 27%, which reduced to 18% in 2017 which is about 24,000 under five deaths. The rate of improvement in pneumonia deaths is much slower than the other cause. Pneumonia control is complex. It requires strong integration across a range of partners and sectors to deliver 10+ interventions that protect against, prevent, diagnose, and treat pneumonia. Yet today, pneumonia suffers from low visibility, prioritisation, and funding within this complex landscape.
The government of Bangladesh adopted the Integrated Management of Childhood Illness (IMCI) strategy
in 1998, and facility-based IMCI had been scaled up in all districts and more than 420 upazilas (sub-districts) by 2014. In the majority of union level facilities, IMCI is performed by paramedics. In addition, IMCI is practiced in community clinics. The 4th Health Population Nutrition Sector Program (2017-2022) envisions improving the quality of IMCI services through strengthening of existing systems and innovations.
There are challenges in both demand side as well as supply side. 46% of children with symptoms of pneumonia are taken to a health facility or qualified provider for advice and 63% of children under five with symptoms of pneumonia received antibiotic treatment. There is lacking in adequate preparedness at service delivery points. Thus, a range of barriers—from limited prevention to low care-seeking behavior to gaps in health worker skills—continue to impede the coverage and quality of proven interventions.
Tackling pneumonia is neither difficult nor expensive.The solution to address the crisis is available and is known. In 2009 and 2013, the World Health Organization (WHO) and UNICEF published the integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea (GAPPD) outlines a set of core interventions to successfully prevent, protect, and treat children who are at risk of dying from Pneumonia. There are 7 Pneumonia specific indicators to monitor progress which is -• protecting children by establishing and promoting good health practices: Exclusive Breast Feeding, • preventing children from becoming ill from pneumonia : Vaccine coverage by 1 year of age of the children (PCV3, PENTA3, MR1), • treating children who are ill from pneumonia : appropriate care seeking and antibiotic treatment.
Unfortunately, many children are dying from pneumonia that could be easily and cheaply treated. Poverty and pneumonia are inextricably linked. The children most at risk are invariably from the poorest families in rural regions and urban slums. They are the most likely to be malnourished and in the risk of missing vaccination or least likely to be diagnosed and treated appropriately.
Save the Children in Bangladesh is implementing common approaches Treating Children Close to Home, Saving Newborn Lives and Nourishing the Youngest (IYCF), all of which contribute to reducing child deaths from pneumonia–through community health worker, through maternal and newborn health interventions and through good nutrition and feeding for children up to 2 years old. Save the Children’s Pneumonia Centenary Commitment (PCC) was launched in early 2017, linked to its 100th anniversary and as a key objective within its Survive Breakthrough to ensure that no child dies from preventable causes before their fifth birthday. Over this period of time, Save the Children has fostered greater partnership with the ministry, UNICEF, academicians, professional organizations, researchers with the aim of building a movement of stakeholders to tackle this challenge together.
The year 2020 has came up in the context of COVID-19 pandemic and with an alert -the threat to child survival and health. In contrast to the direct impact of COVID-19, the broader effects of the pandemic on child health are significant. According to a study covering 118 low- and middle-income countries by the Johns Hopkins Bloomberg School of Public Health, an additional 1.2 million under-five deaths could occur in just six months due to reductions in routine health service coverage levels and an increase in child wasting. Data collected by the WHO, UNICEF, Gavi, and the Sabin Vaccine Institute showed that country lockdowns measures had substantially hindered the delivery of immunisation services in at least 68 countries, putting approximately 80 million children under the age of 1 at increased risk of contracting vaccine-preventable diseases.
Children living in countries that already bear disproportionate impacts of pneumonia must now also contend with potentially catastrophic impacts of the COVID-19 pandemic which threatens to reverse decades of progress in protecting the world’s children from the preventable illnesses. Hence any effort to improve overall child survival must make the reduction of pneumonia’s death toll a priority.
Save the Children and Unicef jointly organised a Virtual Roundtable for commemoration of World Pneumonia Day 2020 in Dhaka, in partnership with Prothom Alo. The discussion covered the various aspect of childhood pneumonia- especially in the context of COVID. It was clear from the talks that Government have a vital role to play, both through policy, its implementation and ensuring that the infrastructure is supportive, and through helping to fill the gap the health systems facing. The voice of the panelists was heard echoing all of us to act together for our children to survive and thrive. It will contribute to developing strategic guidance as well as an implementation road map that country can use for the reduction of mortality of children from pneumonia, the biggest infectious killer of under-five children.
Insecticide-treated bed nets have helped in the fight against malaria but no magic bullet exists in the battle against pneumonia. Instead, what is required is action at all levels.
One year ago, the Global Forum on Childhood Pneumonia held in Barcelona, Spain, where countries collectively committed to taking decisive action to reduce child pneumonia deaths to the levels required to achieve both the Global Action Plan for Pneumonia and Diarrhea (GAPPD) target and the Sustainable Development Goal (SDG) for child survival.
At the Global Forum, attendees agreed to strengthen Primary Health Care (PHC), increase investments, accelerate multisector action, and fast-track innovations to reduce pneumonia deaths to less than 3 per 1,000 live births by 2025 and under five mortality to less than 25 per 1,000 live births by 2030.
Then COVID-19 hit, requiring our immediate attention and dedicated focus. It has created both challenges and opportunities to advance the six strategic actions. While the pandemic has made it more difficult to maintain routine health services for children, especially vaccination, the increased infection control measures and social distancing have reduced the spread of other infections. And the support that has been provided to strengthen respiratory care for COVID-19 patients – especially pulse oximetry, medical oxygen and related therapies – will help reduce pneumonia deaths among children, and increase newborn survival as those technologies are made available throughout healthcare systems.
One year later the global forum of childhood pneumonia organised a series of three virtual roundtables on 9 March, 16 March and 6 April 2021 to provide government/countries with an opportunity to share best practices and highlight challenges in implementing the Global Forum Declaration during a pandemic. The plan for those roundtables to culminate in an event later in the year, led by a delegation of Health Ministers who attended the Global Forum to reflect on the new challenges brought by COVID-19 and to re-assess how countries can ensure that the pandemic response contributes to reductions in all-cause pneumonia deaths. Dr. Md. Shamsul Haq, Line Director MNCAH, DGHS presented Bangladesh context in the April 6 webinar while Dr. Sharif, Program Manager NNHP & IMCI and Prof. Shahidullah, Chairman Technical advisory committee for COVID-19 took part in the discussion of other two webinars.
Considering the changing context and overall childhood pneumonia situation, it is imperative to develop a national strategy for childhood pneumonia management and its implementation plan within the broader child health strategy of the country. The strategy will provide concrete priorities and recommendations—as well as coordination and accountability mechanisms—to strengthen pneumonia control in a manner that is integrated into existing policies and strategies of newborn and child health and health service delivery platforms (e.g., IMCI). This strategy will place an emphasis on interventions that show the most potential to reduce morbidity and mortality, including: immunisation (including PCV, Hib vaccines), oral antibiotics (Amoxicillin DT), reduction of household air pollution, WASH and improved nutrition. Ultimately it will contribute to improved child survival of the country.
Insecticide-treated bed nets have helped in the fight against malaria but no magic bullet exists in the battle against pneumonia. Instead, what is required is action at all levels.The willingness to tackle pneumonia is a test of the commitment because it requires a global partnership, the transfer of resources and an eagerness to put the interests of the poorest and most vulnerable first. Above all, it requires a willingness to act, not only talk.
* Sabbir Ahmed is Advisor, PCC project, Save the Children in Bangladesh.