Fighting for Breath. Call to Action by ISGlobal

FIGHTING FOR BREATH CALL TO ACTION End childhood pneumonia deaths

Biggest killer, yet forgotten

Many countries are off track to reach globally agreed targets

Pneumonia is the world’s leading infectious killer of children, claiming the lives of more than 800,000 children under the age of five every year, more than 2,000 every day. It is a shocking demonstration of pervasive health inequities disproportionately affecting the most deprived and marginalised children in low- and middle‑income countries. It represents a violation of children’s right to survival and development, as enshrined in the UN Convention on the Rights of the Child. Yet pneumonia has been largely forgotten on global and national health agendas. We can and must change this. 1

In 2013, the World Health Organization (WHO) and UNICEF published a comprehensive global framework – the Integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD) – with the goal to end preventable pneumonia and diarrhoea deaths by 2025. It set a target of reducing pneumonia deaths in children to less than three per 1,000 live births by 2025. If current trends continue, the world will not meet this target and many countries will not reach the SDG3 child mortality target of 25 deaths per 1,000 live births.

Almost all child pneumonia deaths are preventable. However, progress on reducing these deaths is slower than for most other major killers of children (Figure 1) – and too slow to achieve the Sustainable Development Goal (SDG) of ending preventable child deaths by 2030.

Nigeria had the largest number of child pneumonia deaths in 2018, followed by India, Pakistan, the Democratic Republic of Congo (DRC) and Ethiopia. Together, these five countries

Figure 1: Deaths of children under five by infectious disease, 2000 vs 2018 1,755,000

Pneumonia

1,200,000

Diarrhoea

Sepsis

Malaria

Tetanus/Meningitis/ Encephalitis

Measles

54%

802,000

437,000

64%

30%

482,000 339,000

656,000 272,000 513,000 162,000 483,000 90,000

59% 68%

81% 2000

HIV/AIDS

233,000 76,000

67%

2018 Percentage decline

Source: UNICEF analysis based on WHO and Maternal and Child Epidemiology Estimation Group interim estimates produced in September 2019, applying cause of deaths for the year 2017 to United Nations Inter-agency Group for Child Mortality Estimation estimates for the year 2018

Children left behind

account for more than half of all deaths due to pneumonia among children under five years. Only three of 30 pneumonia high-burden countries – Bangladesh, Indonesia and China – Under-five deathsfrom (in thousands) by country Child deaths pneumonia are concentrated in the are on track to achieve the GAPPD target by 2025 (see world’s poorest countries and within these countries it is Annex 1 for progress across 30 high-burden countries). the most deprived and marginalised children who suffer The 2019 Pneumonia and Diarrhoea Progress Report Card the most. Children from the poorest families living in developed by International Vaccine Access Centre (IVAC) low- and middle‑income countries (LMICs) are nearly 0 40 120 shows that countries are not making sufficient progress twice as likely80to die before their fifth160 birthday as children and calls for greater investment in the development of from wealthier families, because of social and economic high‑quality data that can be collected more regularly to by country Under-five deaths (in thousands) inequalities and poor access to basic, good-quality health improve our understanding of where countries are progressing services through poorer provision or out‑of‑pocket or lagging on key indicators. Figure 2 looks at how child costs. They are further disadvantaged by high rates pneumonia death rates are changing over time. The vertical of malnutrition, co-infections with other diseases, Southcharts Sudan the death rate and the size of the bubble indicates axis exposure to polluted air, and limited access to safe water, 0 40 80 120 160 the number of deaths caused by pneumonia in 2018 for each sanitation and hygiene. country, while the horizontal axis measures the rate of decline. It shows that in too many countries with a high burden of child pneumonia deaths the rate of decline is too slow. 6

Somalia

Nigeria

Guinea

frican Republic

Angola

Figure Pakistan 2: Child pneumonia mortality rate and average annual rate of reduction, 2000–18 30

West anddeaths Central Under-five deaths (in thousands) by country Under-five (inAfrica thousands) by country

Ethiopia

tic ad of

Eastern and Southern Africa

Chad

Middle East and North Africa

Angola

Tanzania Indonesia

Somalia

Nigeria

Under-five mortality rate due to pneumonia per 1,000 live births, 2018

Ethiopia

Somalia

India

120

GAPPD target:

Nigeria

China South Sudan

South Asia 40 160 80 East Asia and Pacific

120

3 under-five West and Central Africa deaths

Latin America and Caribbean

Eastern and Southern Africa

North America

Middle East and North Africa

Eastern Europe and Central Asia

South Asia

Western Europe

per 1,000 live births

20 Tanzania South Sudan

160

15 East Asia and Pacific Guinea Guinea India GAPPD target: Average annual rate of reduction in pneumonia under-five mortality, 2000−18 (%) 3 under-five deaths Latin America and Caribbean

African Republic

per 1,000 live births

Central African Republic

North America

China Angola

Pakistan

Eastern Europe and Central Asia

Angola

Western Europe

Pakistan

duction in pneumonia under-five mortality, 2000−18 (%) Ethiopia 10

atic c of

Ethiopia

Democratic Republic of Congo Indonesia

Tanzania Indonesia

Tanzania

India

GAPPD target: 3 under-five deaths per 1,000 live births

China

West and Central Africa

West an

Eastern and Southern Africa

Eastern

Middle East and North Africa

Middle E

South Asia

South A

East Asia and Pacific

East Asi

GAPPD target: 3 under-five deaths Latin America and Caribbean per 1,000 live births

North America

North A

Eastern Europe and Central Asia

Eastern

Western Europe

Western

Average annual rate of reduction in pneumonia under-five 2000−18 (%) under-five mortality, 2000−18 (%) Average annual rate mortality, of reduction in pneumonia

Source: UNICEF analysis based on WHO and Maternal and Child Epidemiology Estimation Group interim estimates produced in September 2019, applying cause fractions for the year 2017 to United Nations Inter-agency Group for Child Mortality Estimation estimates for the year 2018.

Latin Am

Tackling childhood pneumonia

needed to ensure that all children have clean air to breathe, sufficient nutritious food to eat, and access to safe water, sanitation, and hygiene. Figure 3 illustrates the three pillars of the approach needed to put the GAPPD into operation.

Reducing the number of children getting sick and dying from pneumonia will require achieving universal access to primary health care, so that all children have access to vaccination and nutrition services, and to goodâ€‘quality diagnosis and treatment. Multi-sectoral actions are

Figure 3: Critical areas for tackling pneumonia INNOVATION

INCREASE VACCINATION COVERAGE

PROTECT

PREVENT PNEUMONIA IN CHILDREN

REDUCE AIR POLLUTION

CHILDREN FROM PNEUMONIA

IMPROVE BREASTFEEDING PRACTICES

IMPROVE ACCESS TO SAFE WATER, SANITATION AND HYGIENE

REDUCE PNEUMONIA MORBIDITY AND MORTALITY AND IMPROVE CHILD SURVIVAL

INCREASE CARESEEKING ENSURE ACCESS TO ESSENTIAL COMMODITIES

SCALE UP INTEGRATED SERVICE DELIVERY AND QUALITY OF CARE

ENSURE ADEQUATE NUTRITION

ACHIEVE UNIVERSAL HEALTH COVERAGE TO DELIVER FOR ALL CHILDREN

INVEST IN HEALTH WORKERS

DIAGNOSE AND TREAT CHILDREN WITH PNEUMONIA

Source: Adapted from WHO/UNICEF, 2013. Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025: The Integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD)

PREVENT pneumonia in children Increase vaccination coverage

situations. Gavi, the Vaccine Alliance, has supported the introduction and scale-up of PCV in many low-income countries, yet lower-middle and middle-income countries not eligible for Gavi support are lagging behind. In the three countries with the highest number of pneumonia deaths, PCV coverage is only 57% in Nigeria, 6% in India and 79% in Pakistan. 14

Improved vaccination coverage has contributed to significant reductions in child deaths, saving two to three million lives a year and protecting millions more children from disease and disability. Immunisation also creates contact points between families and health services for the provision of health services. Each dollar invested in immunisation in 91 LMICs from 2021–30 provides a return of $20 in benefits; this increases to $51 when considering broader societal benefits of people leading longer and healthier lives.

Children from the poorest families, the most remote areas and marginalised groups are left behind in immunisation. Survey data across 72 low- and middle-income countries from 2012–17, for example, indicate a gap of 25 percentage points for DTP3 coverage between children in the poorest and richest households.

Several vaccines protect against pneumonia: Haemophilus influenzae type b (Hib), pneumococcal conjugate vaccines (PCV), measles vaccine (MCV), and diphtheria, tetanus and pertussis (DTP). However, nearly 20 million children still miss out on basic vaccinations, with global coverage of three doses of DTP and one dose of the measles vaccine continuing to stall at 86% in 2018. In 2018, approximately 39 million children globally did not receive the recommended three doses of the Hib vaccine and 71 million did not receive the recommended three doses of PCV, putting them at higher risk of pneumonia (Figure 4). Many countries still have not introduced PCV because of a variety of factors, including high vaccine prices, underfunded health budgets, and conflict

Governments must improve immunisation delivery through increasing domestic investment, strengthening primary health care, creating a reliable supply chain system, and focusing on children missing out. Donors and the global health community should support countries to achieve these steps, particularly poorer countries and those experiencing humanitarian crises. Gavi’s third replenishment, in June 2020, must raise at least $7.4 billion to support the delivery of its 2021–25 strategy to immunise 300 million people and save up to eight million lives. Donors should make significant

Figure 4: Estimated coverage of pneumonia-fighting vaccines in 2018, by World Bank income group 100 90

Immunisation coverage (%)

80 70 60 50 40 30 DTP3

MCV1 10 0

Hib3 PCV3 High income

Upper-middle income

Lower-middle income

Source: WHO/UNICEF estimates of national immunisation coverage, 2018 revision Note: World Bank income groups, 2018

Low income

Global

particulate matter, is a contributory factor in an additional 38%. One of the reasons that air pollution is such a major factor is the low level of access to clean fuels and technologies for cooking, especially in sub-Saharan Africa. In Nigeria, DRC, Ethiopia, Tanzania, Niger, Chad, Burkina Faso, Madagascar, South Sudan and Mali, less than 10% of the population has access to clean fuels and technologies for cooking. This needs to be addressed by governments.

pledges to Gavi, while ensuring this investment drives a strong policy agenda on equity and strengthening primary health care systems. In its next strategic period, Gavi aims to accelerate improved access to immunisation for the worldâ€™s poorest children, while leaving a stronger health system in the countries it supports. Gavi remains committed to prioritise a market-shaping role to improve vaccine affordability and access, including accelerating new entrants to the vaccine market to ensure genuine competition, which could drive down prices and improve quality.

Improve access to safe water, sanitation and hygiene

Reduce air pollution

Good hygiene practices help prevent pneumonia and other illnesses, including diarrhoea. Studies have shown that improved handwashing with soap reduces pneumonia risk by up to 50% by reducing exposure to bacteria and other microbial agents. But in least developed countries (LDCs) in 2017, nearly three-quarters of the population lacked handwashing facilities with soap and water, and two-thirds lacked basic sanitation services at home. Lack of water, sanitation, and hygiene services in health care facilities places newborns and young children at great risk. In LDCs one in five health care facilities has no water, sanitation or health care waste management services.

Air pollution (both indoor and outdoor) is a significant risk factor for pneumonia deaths among children. The percentage of child pneumonia deaths attributable to air pollution varies widely across high-burden countries, ranging from 27% in Indonesia to 56% in Niger; however, the impact might be under- or over-estimated. Increasing urbanisation and urban population growth in many high-burden pneumonia countries may increase the number of children exposed to air pollution. 19

According to Global Burden of Disease estimates, household air pollution from using solid and unclean fuels for cooking and heating contributes to 62% of air pollution-related child pneumonia deaths, while outdoor pollution, especially

Jamillah, age six months, is being treated for pneumonia at a hospital in Turkana, Kenya. Photo: Nina Raingold/Save the Children

PROTECT children from pneumonia Ensure adequate nutrition

funding deficit. This will require significantly increased domestic and innovative financing, supported by international development assistance. Nutrition financing also needs to be better aligned with investments in primary health care to achieve universal health coverage. 35

Malnutrition is a risk factor in nearly half of all deaths among children under five. In 2018, 50 million children suffered from wasting and 149 million from stunting. A severely undernourished child is nine times more likely to die from common infections, including pneumonia, compared with a well-nourished child. Children from the poorest 20% of households are more than twice as likely to be stunted and have a 40% higher risk of being wasted as those from the richest 20%. And while around 80% of children who complete treatment for severe undernutrition are cured, currently less than 20% of those who need treatment have access to it. 29

Improve breastfeeding practices

Newborns are particularly susceptible to infections, and pneumonia claimed 153,000 newborn lives in 2018 (6% of newborn deaths). Babies born to mothers who enter pregnancy well-nourished, who receive nutrition services during and after pregnancy, and who exclusively breastfeed over the first six months of life are less likely to contract or die from pneumonia and other infections. Immediate breastfeeding in the first hours and days of a baby’s life provides protection against pneumococcal bacteria and other pathogens, and strengthens a baby’s natural defences, yet rates of colostrum feeding in many high pneumonia risk areas remain too low. Breastfeeding exclusively until six months of age, and continued breastfeeding with the gradual introduction of complementary foods up until two years of age or beyond, can similarly reduce the risk of babies contracting and dying from pneumonia. Despite the protective properties of breast milk, less than half of infants in low-income countries, and only one third in lower-middleincome countries, are exclusively breastfed for the first six months of life.

Countries with high burdens of both childhood pneumonia deaths and malnutrition, especially acute malnutrition, should scale up nutrition-related programmes within primary health care, including improving infant and young child feeding, nutrition counselling, growth monitoring, and work to promote behaviour change around feeding and care seeking. Integrated service delivery approaches, such as integrated management of child illness (IMCI) and integrated community case management (ICCM) are key strategies to address pneumonia at the primary health care level and to integrate the community-based management of acute malnutrition. Financing for nutrition also urgently needs to increase. The Tokyo Nutrition for Growth Summit in 2020 is a critical opportunity to galvanise world leaders to address the current

Nakwan, just seven days old, has pneumonia. She is being treated at a health clinic in northern Kenya. Photo: Fredrik Lerneryd/Save the Children

DIAGNOSE AND TREAT children with pneumonia Increase care seeking

vaccines and treatment for pneumonia, has the largest effect on averting deaths among children under the age of five. Expanded access to primary health care at community level also requires functioning referral and transport pathways, data collection and monitoring. 44

Improved care seeking is critical to ensure sick children are taken to and seen by a health worker who can effectively diagnose and treat them or refer them for special care. Globally, only 68% of children with suspected pneumonia are taken to a health facility. This is far lower in most high-burden pneumonia countries – for example, in Somalia and Benin, only 46% of children with suspected pneumonia are taken for care. Just 60% of children with pneumonia symptoms from the poorest households and 65% in rural areas are taken to a health facility compared with 78% and 74% of children from the wealthiest and urban households. Improving care seeking requires improved engagement and communication with families and communities.

IMCI delivered at primary care facilities and ICCM delivered by community health workers are critical strategies to address pneumonia and other key causes of child illness and death. While there has been progress, the coverage of these services remains patchy, and only a handful of countries have recognised ICCM as a core child survival strategy and rolled it out at scale. Over the past years, the Global Fund has provided substantial support to the scale-up of ICCM, including community health worker training and malaria commodities. Yet, the financing of treatments for pneumonia and diarrhoea, not supported by the Global Fund, has been a major challenge. Very few countries finance community case management through their national health budgets. The recent successful replenishment effort of the Global Fund and upcoming country allocations provide an opportunity to again strongly promote ICCM and leverage country commitments for child health commodities and services, while at the same time clearly defining the overall budget needs and resources gaps.

Scale up integrated service delivery and quality of care Increased demand for services must be matched by improved availability and accessibility of comprehensive, high-quality health services, especially for the most deprived and marginalised children. It has been shown that a package of key interventions delivered at community level, including

Box 1: 13-day-old Emran recovers from severe pneumonia While community health volunteer Honufa was making her regular house-to-house visits in a remote village in the Barisal Division of Bangladesh, she found Sharmin worrying about her 13-day-old son, Emran. Sharmin complained that Emran couldn’t breastfeed, was breathing rapidly, and that his chest was drawing in. Honufa immediately recognised the danger signs of pneumonia and advised Sharmin to go to the nearest community clinic. Within 15 minutes of being seen by Naznine, a community health care provider at the clinic, Emran was diagnosed with pneumonia and treated with his first dose of dispersible Amoxicillin. Naznine showed Sharmin how to give the tablet at home for the next seven days, and explained how to care for Emran at home. Thanks to the quick referral, diagnosis and treatment, Emran made a full recovery. Like all community health care providers in Bangladesh, Naznine had received training on the diagnosis and management of pneumonia. The Government’s investment in strengthening health services at the community level, with the support of organisations like Save the Children, means that communities now have access to health services and a trained health worker closer to home. They no longer have to travel to sub-district facilities and bear the huge financial burden of hospital treatment. It also means that treatment can be started much more quickly.

Emran, seen here with his mother, Sharmin, was treated for pneumonia at a community clinic in Bangladesh. He was referred for treatment by a trained community health volunteer. Photo: Md. Touqir Islam/Save the Children

Ensure access to essential commodities

minimum of 44.5 doctors, nurses or midwives for every 10,000 people. Health worker shortages are most widespread in low- and middle-income countries. Community health workers are recognised as a crucial workforce to deliver life-saving interventions, yet support for community health workers and their integration into health systems and communities remain uneven across and within countries.

Detecting and managing child pneumonia is challenging as no simple diagnostic test exists, so health workers rely on assessing and interpreting signs and symptoms. This carries the risk of both under- as well as over-diagnosis and results in some children failing to get access to treatment while others receive treatments they don’t need, contributing to antibiotic resistance and wastage of medicines. Affordable and highly effective amoxicillin in dispersible tablet form is the recommended first-line treatment for childhood pneumonia but coverage remains low in many settings. Of great concern is the almost complete lack of access to pulse oximetry, a non-invasive mechanism for measuring oxygen levels in blood, and the availability of medical oxygen at all levels of the healthcare system in high-burden countries, meaning that many children die from pneumonia for lack of oxygen. Unitaid has recently invested more than $40 million to increase access to pulse oximeters in several high-burden countries, which could improve the identification and referral of very sick children and save many lives.

Achieve universal health coverage to deliver for all children Ending preventable child deaths from pneumonia can only be achieved if countries make faster progress in achieving universal health coverage, and pneumonia will be the litmus test of whether universal health coverage can truly deliver for all children. Governments have the core responsibility to fulfil this right, ensuring children have access to an essential package of good-quality health care, free at the point of use, prioritising those furthest behind. Health systems must deliver good-quality care for children at all levels. 48

While there has been global progress on delivering universal health coverage, a third of the world’s population (34%) is still missing out. There are huge variations across countries with low-income countries and those affected by conflict having the lowest coverage (see Map 1). Care-seeking for a child showing symptoms of pneumonia is the indicator used to monitor ‘child treatment’ in the UHC Service Coverage Index. Yet, currently most high‑burden pneumonia countries fall far below the target of 90% of children with pneumonia symptoms being taken for healthcare. 49

Invest in health workers

A health worker with the right training, skills, medicines and supplies, based in a functional health centre or his/her community, is needed to prevent and treat pneumonia. However, countries are facing severe health workforce shortages, with the quantity and quality of health workers under threat. Globally, an estimated 18 million more health workers are needed by 2030 to reach the SDG targets on universal health coverage. WHO standards call for a

Map 1: Universal health coverage across countries

Health coverage on a scale of 0 to 100 Health coverage on a scale of 0 to 100 80 or more 70–79 60–69 50–59 80 or more 70–79 60–69 50–59

40–49 40–49

Less than 40 Less than 40

Data not available Data not available

Not applicable Not applicable

Source: WHO, 2019. Primary health care on the road to universal health coverage: 2019 monitoring report. WHO: Geneva. Note: This map has been produced by the WHO. The boundaries, colours or other designations or denominations used in this map and the publication do not imply, on the part of the World Bank or WHO, any opinion or judgement on the legal status of any country, territory, city or area or of its authorities, or any endorsement or acceptance of such boundaries or frontiers.

Government spending on health care is far too low in many parts of the world, resulting in patients picking up the bill for their treatment. Governments should increase domestic public health expenditure towards a target of 5% of GDP, prioritising spending at the primary healthcare level and raising revenue in an equitable way. The Global Financing Facility for Women’s Children’s and Adolescents’ Health has a key role to play in helping countries to grow domestic resources and structure health services to reach those left furthest behind.

The first-ever UN High-Level Meeting on Universal Health Coverage in September 2019 saw the endorsement of a Political Declaration with commitments on strengthening primary healthcare, health financing and leaving no one behind. This followed the Astana Declaration in October 2018, which refocused efforts on primary health care. Governments must be held to account to deliver on these promises, both at national level and through global reporting and accountability mechanisms, such as at the World Health Assembly, SDG reporting and UHC2030. 53

Box 2: Addressing pneumonia in humanitarian contexts A long-standing barrier to PCV use in in the humanitarian context has been price. After sustained advocacy on this front, in 2016 GSK and Pfizer committed to offer their PCV vaccines at the lowest global price in humanitarian settings. Save the Children, Médecins Sans Frontières, WHO and UNICEF set up the Humanitarian Mechanism to operationalise these commitments. Two years in, the mechanism has contributed to the immunisation of around 647,000 children and has the potential to increase immunisation access significantly in the future.

Common causes of illness and death are often intensified in humanitarian contexts, as are many pneumonia risk factors, such as malnutrition, missed vaccination opportunities, air pollution, and overcrowding, while health systems are at risk of breaking down. Pneumonia is one of the top causes of morbidity in crisis contexts, accounting for 20–35% of deaths among children under five. Four out of five countries identified as having exceptionally high humanitarian need in 2019 – DRC, Ethiopia, Nigeria and South Sudan – are also among the ten countries with the highest number of child pneumonia deaths or the highest child pneumonia mortality rate.

Diagnosing and treating children While health systems may break down or become inaccessible to large parts of the population during humanitarian crises, it has been shown that community health workers have the potential to provide continued services, including ICCM, creating a lifeline of health care provision to affected populations. ICCM is a critical approach to helping reach the most deprived and marginalised children and it should be prioritised and strengthened in humanitarian responses. Concerted effort is needed to overcome challenges to delivering ICCM in these situations, such as obstacles to accessing referral centres, medicine and supply shortages, disrupted supervision, increased demand on community health workers and security threats for patients and health workers.

Preventing children from becoming sick Unvaccinated children are disproportionately found in fragile or conflict-affected states. Almost half are in just 16 countries – Afghanistan, Central African Republic, Chad, DRC, Ethiopia, Haiti, Iraq, Mali, Niger, Nigeria, Pakistan, Somalia, South Sudan, Sudan, Syria and Yemen. Immunisation programmes often come to a halt in humanitarian contexts, and when they are reinstated the only vaccines reliably and consistently introduced are to protect against measles, polio, and tetanus. This is despite the Vaccination in Acute Humanitarian Emergencies WHO Framework listing other routine vaccines for consideration in crises, including PCV. 57

One-year-old Luc is treated for severe pneumonia at a hospital in the DRC; his mother, Makenda, waits at his side. Photo: Jonathan Hyams/Save the Children

INNOVATE to improve access to affordable and cost-effective pneumonia technologies and services such as temperature and pulse rate, are advancing rapidly and need to be incorporated within health services. Lung ultrasound – more portable and less dangerous and costly than x-ray imaging – has been shown to be feasible in low‑resource settings.

Only 3% of global infectious disease research spending is currently allocated to pneumonia, despite pneumonia causing 15% of deaths in children under the age of five. Innovations can catalyse and accelerate progress, but there must be an emphasis on innovations that will meet the needs of high-burden countries and improve equity. 60

Promising treatment innovations include ways to produce, store, deliver and transport medical oxygen, more robust ventilation support systems and simplified antibiotic treatment schedules with child-friendly formulations. However, there is an alarming lack of an antibiotic drug pipeline in an age of antimicrobial resistance; this problem must be addressed. There is also a need for innovations that can reduce two of the leading risk factors for child pneumonia death – wasting and poor air quality. All of these areas should be the focus of increased research and development in the years ahead. Public–private partnerships have a role to play in supporting this.

New vaccines targeting the leading viral cause of pneumonia (Respiratory Syncytial virus, RSV) are in the final stages of development, and new technologies that would reduce reliance on cold chain vaccine storage are showing great promise. Research is also under way to help identify optimal PCV mass immunisation strategies for crisis-affected populations, as well as looking at the potential of one-off PCV campaigns amongst displaced populations. There is an urgent need for cost-effective diagnosis of illnesses such as pneumonia. Devices that measure respiratory rate, plus pulse-oximetry and other vital signs,

Sohai, age two, being treated for acute pneumonia at a primary health centre in Cox’s Bazar, Bangladesh. Photo: Jonathan Hyams/Save the Children

The time to act is now – The Fighting for Breath Global Forum With ten years left to deliver on the SDGs – and five on the GAPPD targets – now is the time to act to reduce pneumonia deaths and improve child survival. Failure to do so could leave 11 million children robbed of their futures. The Fighting for Breath Global Forum on Childhood Pneumonia, taking place from 29–31 January 2020 in Spain, is a critical opportunity to galvanise urgently needed national action and mobilise country governments, development partners and the donor community. The Forum will also demonstrate the power of partnerships, such as the Every Breath Counts coalition.

Meeting on Universal Health Coverage, where governments made commitments that must now be translated into action and monitored. The Global Forum will also take place in the run-up to the Gavi replenishment in June 2020 and the Tokyo Nutrition for Growth Summit later in 2020 and will encourage donors to support governments by strengthening immunisation, nutrition, primary health care and universal health coverage. The Forum is a real opportunity to galvanise action on combatting child pneumonia. We encourage governments and partners to drive progress towards a world in which no child dies needlessly of pneumonia.

The Global Forum continues the work of the Global Conference on Primary Health Care and the UN High-Level

A global call to action on childhood pneumonia 1. Develop pneumonia control strategies as part of wider plans for universal health coverage and commit to reducing child pneumonia deaths to fewer than three per 1,000 live births, the target set by the Integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD).

2. Strengthen quality primary health care and action on pneumonia as part of national multi-sectoral plans and through integrated strategies (including nutrition, water, sanitation and hygiene, and air pollution), including at community level, focusing on the most deprived and marginalised children.

3. Increase domestic government investment in health and nutrition (to at least 5% of GDP on health) and ensure that increased spending improves access to child health and nutrition services, including by removing user fees, addressing non‑financial barriers to accessing care, and prioritising primary health services.

4. Improve health governance by ensuring accountability, transparency and inclusiveness in planning, budgeting and expenditure monitoring, including for pneumonia control strategies.

5. Accelerate vaccination coverage by supporting Gavi’s 2020 replenishment and ensuring the investment drives more equitable vaccination coverage and improves vaccine affordability.

6. Enhance official development assistance by increasing allocations to child health services and advancing the achievement of universal health coverage (aligned with national priorities and plans), including through pledges as part of Gavi replenishment and Nutrition for Growth.

7. Engage the private sector to improve access to affordable, quality vaccines, diagnostic tools, new antibiotics, medicines and medical oxygen, especially for the most deprived and marginalised children.

8. Measure and report progress in achieving universal health coverage to promote accountability for the development of stronger health systems that deliver quality primary health care and reduce child deaths, including from pneumonia, as well as against SDG child survival and GAPPD targets.

9. Prioritise research, development and innovation to improve access to the most affordable and cost-effective pneumonia prevention, diagnosis, referral and treatment technologies and services.

10. Champion multi-sectoral partnerships between the child health and nutrition communities and the broader infection control, clean air, water, sanitation and hygiene, and development financing communities.

Annex 1 – Pneumonia high-burden countries 64

Country

Number of under-five deaths from pneumonia (2018)

Under-five mortality rate due to pneumonia per 1,000 live births (2018)

Percentage of under-five deaths due to pneumonia (2017)

Nigeria

161,515

21.7

18.6

1.5

Later than 2050

India

126,535

5.2

14.3

6.7

2026

Pakistan

57,970

9.7

14.2

4.4

2044

DRC

39,796

11.5

13.4

3.0

Later than 2050

Ethiopia

32,006

9.0

16.8

6.4

2035

Indonesia

19,152

4.0

15.8

4.8

2024

China

18,382

1.1

12.6

10.7

2009

Chad

17,783

27.2

23.7

1.6

Later than 2050

Angola

16,270

12.9

17.3

6.4

2040

Tanzania

15,288

7.4

14.3

6.2

2032

Somalia

15,165

24.1

20.7

2.1

Later than 2050

Niger

12,803

12.3

15.5

6.8

2038

Mali

12,557

15.8

16.7

4.7

Later than 2050

Bangladesh

11,967

4.1

13.5

8.1

2022

Sudan

11,463

8.5

14.4

5.3

2037

Afghanistan

11,086

9.2

14.9

5.1

2039

Mozambique

10,206

9.2

12.9

4.4

2043

Côte d’Ivoire

10,142

11.3

14.4

1.7

Later than 2050

Uganda

10,065

6.2

13.6

6.9

2028

Cameroon

9,955

11.1

15.0

4.7

2045

Philippines

9,919

4.5

15.8

3.2

2031

Kenya

8,856

6.0

14.7

5.8

2029

Guinea

8,072

17.8

18.2

1.9

Later than 2050

South Sudan

7,641

19.7

20.3

3.0

Later than 2050

Benin

5,193

12.5

13.8

3.4

Later than 2050

Haiti

3,643

13.5

20.9

3.5

Later than 2050

Sierra Leone

3,491

13.6

13.2

5.3

2046

Central African Republic

2,949

17.8

15.5

1.3

Later than 2050

Equatorial Guinea

539

12.4

15.0

3.1

Later than 2050

Comoros

315

11.9

17.9

3.0

Later than 2050

Average annual rate of reduction in pneumonia deaths 2000–18 (%)

Year country is expected to reach the 2025 GAPPD target at current rate of progress

Endnotes 1 UNICEF analysis based on WHO and Maternal and Child Epidemiology Estimation Group interim estimates produced in September 2019, applying cause fractions for the year 2017 to United Nations Inter-agency Group for Child Mortality Estimation estimates for the year 2018.

15 Some Gavi-eligible countries still have not introduced PCV (Chad, Somalia, South Sudan, Vietnam, Ukraine) or have low coverage (India, Nigeria, Central African Republic, Indonesia, Laos, Mongolia, Papua New Guinea), based on International Vaccine Access Center (https://view-hub.org/).

2 Convention on the Rights of the Child: https://www.unicef.org/ child-rights-convention/convention-text

16 International Vaccine Access Center. https://view-hub.org/, last access 29 October 2019.

3 Between 2000 and 2018, child pneumonia deaths fell by 54% compared with 81% for measles, 68% for tetanus, 67% for HIV/AIDS, 64% for diarrhoea, and 59% for malaria. WHO and Maternal and Child Epidemiology Estimation Group (MCEE) estimates 2017.

17 UNICEF analysis of DHS and MICS survey reports via WHO Health Equity Monitor for the period 2012–2017. 18 Gavi – The Vaccine Alliance (2019). Gavi sets ambitious goal to immunise 300 million people by 2025, leaving no one behind (Press release). https://www.gavi.org/library/news/press-releases/2019/ gavi-sets-ambitious-goal-to-immunise-300-million-people-by-2025leaving-no-one-behind/, last access 29 October 2019.

4 Calculation of progress towards GAPPD target based on average annual percentage change 2000 to 2017; WHO and UNICEF (2013). Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025: The integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD). 5 Goal 3.2 of the Sustainable Development Goals.

19 IHME (2017). Global Burden of Disease. Available at: https://vizhub. healthdata.org/gbd-compare/

6 High pneumonia burden refers to both numbers of pneumonia deaths and mortality rates due to pneumonia (see list of countries in Annex 1).

20 IHME (2017). Global Burden of Disease. Available at: https://vizhub. healthdata.org/gbd-compare/

7 Calculation of progress towards GAPPD target based on average annual percentage change 2000 to 2017.

21 UNICEF (2019). Silent suffocation in Africa: Air pollution is a growing menace. Available at https://www.unicef.org/reports/silent-suffocationin-africa-air-pollution-2019

8 The Report Card includes a total of 23 countries – the top 15 by number of under-five pneumonia and diarrhoea (combined) deaths, and the top 15 by under-five pneumonia and diarrhoea (combined) mortality rate, with seven countries appearing on both lists. It scores countries based on the latest available data for ten GAPPD indicators – Protection: exclusive breastfeeding; Prevention: DTP3, MCV1, Hib3, PCV3, and RotaC coverage; and Treatment: oral rehydration salts and zinc for diarrhoea, and antibiotics and visiting an appropriate health care provider for pneumonia/ARI. The Report Card is available here: https://www.jhsph.edu/ivac/resources/pdpr/.

22 IHME (2017). Global Burden of Disease. Available at: https://vizhub. healthdata.org/gbd-compare/ 23 IHME (2017). Global Burden of Disease. Available at: https://vizhub. healthdata.org/gbd-compare/ 24 Luby, SP, Agboatwalla, M, Feikin, DR, Painter, J, Billhimer, W, Altaf, A, & Hoekstra, RM (2005). Effect of handwashing on child health: a randomised controlled trial. The Lancet, 366(9481), 225–233.

9 Comparison of under-five mortality rates in richest and poorest quintile for 74 countries with last data point 2012 or later. Source of data is DHS or MICS, accessed via GRID, Save the Children’s Child Inequality Tracker. Data is weighted by number of births per country.

25 Kumar, S et al. “Handwashing in 51 countries: Analysis of proxy measures of handwashing behavior in multiple indicator cluster surveys and demographic and health surveys, 2010–2013.” The American journal of tropical medicine and hygiene 97.2 (2017): 447–459.

10 WHO Immunization. https://www.who.int/news-room/facts-inpictures/detail/immunization, last access 22 October 2019.

26 Least developed countries are low-income countries confronting severe structural impediments to sustainable development, highly vulnerable to economic and environmental shocks and with low levels of human assets. https://www.un.org/development/desa/dpad/least-developedcountry-category.html

11 Johns Hopkins University / International Vaccine Access Centre (2019). Methodology Report: Decade of Vaccines Economics – Return on Investment Analysis. Available at: http://immunizationeconomics.org/ dove-roi

27 UNICEF and WHO (2019). Progress on household drinking water, sanitation and hygiene 2000–2017: special focus on inequalities.

12 WHO (2019). 20 million children miss out on lifesaving measles, diphtheria and tetanus vaccines in 2018 (News release). https://www.who.int/news-room/detail/15-07-2019-20-millionchildren-miss-out-on-lifesaving-measles-diphtheria-and-tetanusvaccines-in-2018, last access 29 October 2019.

28 WHO and UNICEF (2019), WASH in health care facilities: global baseline report. Available at: https://data.unicef.org/resources/wash-in-healthcare-facilities/ 29 Black RE, Victoria CG, Walker SP, Bhutta ZA, Christian P, de Onis M et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet Series: Maternal and Child Nutrition. 2013; 382:427–451.

13 WHO (2019). Global and regional immunisation profile. https://www.who.int/immunization/monitoring_surveillance/data/ gs_gloprofile.pdf?ua=1

30 UNICEF/WHO/World Bank. Joint child malnutrition estimates 2019.

14 The challenge of high vaccine prices continues to be raised as a problem by governments and development partners. At the 72nd World Health Assembly in 2019 countries endorsed a resolution to improve the transparency of markets for medicines, vaccines, and other health products (https://apps.who.int/gb/ebwha/pdf_files/WHA72/A72_ ACONF2Rev1-en.pdf). Previously, at the 67th World Health Assembly (WHA) in 2014, many countries requested greater price transparency, information on cost of production, support for improving negotiation capacity and access to lower prices. Vaccine affordability has also been raised by ministers of health at subsequent WHAs and at the Ministerial Conference on Immunisation in Africa in 2016. This was also a key finding from consultations conducted by the WHO MIC Task Force (see http://who.int/immunization/programmes_systems/ procurement/ v3p/platform/database/en/).

31 UNICEF. Severe acute malnutrition. https://www.unicef.org/nutrition/ index_sam.html, last access 29 October 2019. 32 Comparison of stunting and wasting rates in richest and poorest quintile for 81 countries with last data point 2012 or later. Source of data is DHS or MICS, accessed via GRID, Save the Children’s Child Inequality Tracker. Data is weighted by population under age 5 per country. 33 Shekar, Meera; Kakietek, Jakub; Dayton Eberwein, Julia; Walters, Dylan. 2017. An Investment Framework for Nutrition: Reaching the Global Targets for Stunting, Anemia, Breastfeeding, and Wasting. World Bank, Washington D.C. Available at: https://openknowledge.worldbank.org/ handle/10986/26069

34 Calculation for severe acute malnutrition is based on UNICEF Nutridash, 2016 Edition, and for moderate acute malnutrition on WFP data for 2016. https://www.nowastedlives.org/the-facts

Monitoring Report. Available at: https://www.who.int/healthinfo/ universal_health_coverage/report/uhc_report_2019.pdf?ua=1 51 WHO. Global Health Observatory. UHC service coverage index.

35 Government of Japan (2019), Tokyo Nutrition for Growth Summit 2020: vision and Roadmap – August 2019 version.

52 Stop Pneumonia (2019). Pneumonia Careseeking Scorecard 2019. https://stoppneumonia.org/pneumonia-careseeking-scorecard-2019/

36 UNICEF analysis based on WHO and Maternal and Child Epidemiology Estimation Group interim estimates produced in September 2019, applying cause fractions for the year 2017 to United Nations Inter-agency Group for Child Mortality Estimation estimates for the year 2018.

53 UN General Assembly (2019). Political Declaration of the High-Level Meeting on Universal Health Coverage. Available at: https://www.un.org/pga/73/wp-content/uploads/sites/53/2019/ 09/UHC-HLM-silence-procedure.pdf

37 Lamberti, L et al. (2013). Breastfeeding for reducing the risk of pneumonia morbidity and mortality in children under two: a systematic literature review and meta-analysis. BMC Public Health 13(Suppl 3): S18. https://bmcpublichealth.biomedcentral.com/articles/10.1186/14712458-13-S3-S18

54 UHC2030 is a provides a multi-stakeholder platform to promote collaborative working in countries and globally on health systems strengthening. See www.uhc2030.org. 55 Bellos, A, Mulholland, K, O’Brien, KL, Qazi, SA, Gayer, M, Checchi, F. The burden of acute respiratory infections in crisis-affected populations: a systematic review. Confl Health, 4 (2010), p. 3

38 Khan J, Vesel L, Bahl R, Martines JC. Timing of breastfeeding initiation and exclusivity of breastfeeding during the first month of life: effects on neonatal mortality and morbidity – a systematic review and meta-analysis. Matern Child Health J. 2015;19(3):468–79; UNICEF. Infant and young child feeding, available at https://data.unicef.org/topic/ nutrition/infant-and-young-child-feeding/.

56 Syria, the Democratic Republic of the Congo, Ethiopia, Nigeria and South Sudan are identified as having exceptionally high levels of humanitarian need in 2019. United Nations Office for the Coordination of Humanitarian Affairs (2018). Global Humanitarian Overview 2019. https://www.unocha.org/sites/unocha/files/GHO2019.pdf

39 Lamberti, L.M. et al. (2013). Breastfeeding for reducing the risk of pneumonia morbidity and mortality in children under two: a systematic literature review and meta-analysis. BMC Public Health 13(Suppl 3): S18. https://bmcpublichealth.biomedcentral.com/articles/10.1186/14712458-13-S3-S18

57 WHO (2017). Vaccination in Acute Humanitarian Emergencies: A Framework for Decision Making. Geneva: WHO. 58 WHO (2017). Accessing Affordable and Timely Supply of Vaccines for use in Humanitarian Emergencies: the Humanitarian Mechanism (WHO Working Document). Available at: https://www.who.int/immunization/ programmes_systems/sustainability/The_Humanitarian_Mechanism_ ToRs.pdf?ua=1

40 UNICEF Data. Monitoring the Situation of Children and Women – Infant and young children. Available at: https://data.unicef.org/topic/nutrition/ infant-and-young-child-feeding/, last accessed 20 August 2018

59 Save the Children (2019). Community case management in humanitarian settings – Guidelines for humanitarian workers. Available at: https://resourcecentre.savethechildren.net/node/15870/ pdf/iccm-guide_formatted-online.pdf

41 UNICEF Global databases based on DHS, MICS and other national household surveys, updated August 2019. 42 UNICEF Global databases based on DHS, MICS and other national household surveys, updated August 2019.

60 Brown, R and Head, M (2018). Research Investments in Global Health Study (ResIn). Sizing up Pneumonia Research: Assessing Global Investments in Pneumonia Research 2000–2015. Southampton, UK: ResIn.

43 UNICEF Global databases based on DHS, MICS and other national household surveys, updated August 2019. 44 Black RB, Levin C, Walker N, Chou D, Liu L, Temmerman M for the DCP3 RMNCAH Author’s Group. Reproductive, Maternal, Newborn and Child Health: key messages from disease control priorities 3rd Edition. Lancet 2016

61 Nadimpalli, A et al. (2019). Feasibility of Training Clinical Officers in Point-of-Care Ultrasound for Pediatric Respiratory Diseases in Aweil, South Sudan. Am J Trop Med Hyg, Sep 2019;101(3):689–695; Iorio, G et al. (2015). Lung ultrasound in the diagnosis of pneumonia in children: proposal for a new diagnostic algorithm. PeerJ. 2015; 3: e1374; Ellington, LE et al. (2017). Lung ultrasound as a diagnostic tool for radiographically-confirmed pneumonia in low resource settings. Respir Med. 2017 Jul; 128: 57–64; Zar, HJ, Andronikou, S., Nicol MP (2017). Advances in the diagnosis of pneumonia in children. BMJ 2017;358:j2739; Prina, E, Ranzani, OT, Torres, A (2015). Communityacquired pneumonia. Lancet 286(9998); Lenahan, JL et al. (2018). Multicentre pilot study evaluation of lung ultrasound for the management of paediatric pneumonia in low-resource settings: a study protocol. BMJ Open Resp Res 2018;5:e000340

45 WHO (2016). Health Workforce Requirements for Universal Health Coverage and the Sustainable Development Goals, Geneva. 46 UNICEF (2019). Healthy Mothers, Healthy Babies: Taking Stock of Maternal Health, UNICEF, New York. 47 WHO (2019). WHO guideline on health policy and system support to optimize community health worker programmes. Available at: https://apps.who.int/iris/bitstream/handle/10665/275474/ 9789241550369-eng.pdf?ua=1 48 The Lancet Commission on High-Quality Health Systems in the SDG Era argues that “High-quality health systems should be informed by four values: they are for people, and they are equitable, resilient, and efficient.” A global movement is underway to improve the quality of care for maternal, newborn, and child health services. WHO issued in 2018 the Standards for Improving the Quality of Care for Children and Young Adolescents in Health Facilities. The quality of care standards encompass the delivery of evidence-based clinical services, an elevated experience of care for children and their families, an equipped, motivated, supervised, and supported health workforce, and health facilities replete with essential child health commodities, technologies, and physical resources and infrastructure. Based on these and similar standards for improving the quality of maternal and newborn care, WHO and UNICEF launched The Network for Improving Quality of Care for Maternal Newborn and Child Health (the QoC Network).

62 UN Interagency Group for Child Mortality Estimation. Levels and Trends in Child Mortality. Report 2019. p.15 63 Every Breath Counts is the world’s first public–private partnership to support national governments to end preventable child pneumonia deaths by 2030. This global coalition has 40 members from governments, UN and multilateral health agencies, companies, foundations, and NGOs working together to close the most critical gaps in pneumonia prevention, diagnosis and treatment. See: https://stoppneumonia.org/ 64 The 30 high-burden countries include 22 countries with the highest absolute number of pneumonia deaths and the top 14 countries in terms of pneumonia-specific mortality rates. UNICEF analysis based on WHO and Maternal and Child Epidemiology Estimation Group interim estimates produced in September 2019, applying cause fractions for the year 2017 to UN Inter-Agency Group for Child Mortality Estimation estimates for the year 2018; WHO Global Health Observatory – Causes of deaths 2017.

49 Measured by an index of 16 tracer indicators 50 The UHC service coverage index based on 16 tracer indicators, measuring progress on SDG indicator 3.8.1; WHO (2019). Primary Health Care on the Road to Universal Health Coverage – 2019

Acknowledgements This briefing was prepared by: Save the Children, London, and UNICEF, New York. Organisations and individuals involved in producing this brief: Save the Children:Â Kirsten Mathieson, Simon Wright, Oliver Fiala, Jessica Winn, Katherine Richards, Samy Ahmar, Jason Lopez, Sam Kennedy, Christopher Twiss UNICEF: Anne Detjen, Tyler Andrew Porth, Philippa Lysaght, Jennifer Requejo, and colleagues from the Data & Analytics section of the Division of Data, Analysis, Planning and Monitoring including Danzhen You, Lucia Hug, Padraic Murphy,Â Allysha Choudhury, Richard Kumapley, Chika Hayashi, Vrinda Mehra, Tom Slaymaker, Robert Bain Every Breath Counts Coalition: Leith Greenslade, Androulla Kyrillou ISGlobal: Gonzalo Fanjul, Quique Bassat

Fighting for Breath: Global Forum on Childhood Pneumonia: stoppneumonia.org/latest/global-forum/

Cover: Abrahim, age seven months, after recovering from pneumonia at a hospital in Turkana, Kenya. Photo: Nina Raingold/Save the Children

Some names in this report have been changed to protect identities.

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