November 12th marked World Pneumonia Day. Save the Children has launched a global campaign to stop the disease in its tracks, with the publication of our flagship report Fighting for Breath. In a series of blogs, we take a close look at the challenges and successes of countries around the world in beating pneumonia.
In India, 392,859 under-fives were killed by pneumonia in 2004. The figure fell considerably by 2015 to 178,717. This still equated to more than 20 children every hour. Pneumonia remains one of the country’s biggest child killers, and India does seem to be making some progress in reducing its impact.
This could be attributed to strategic equity targeted approaches within the National Health Mission (NHM), with a clear focus on investing resources in strengthening facilities at the primary health care level.
A number of gaps to close
India faces significant challenges in terms of poor-rich, rural-urban, gender, socio-economic, geographical, Caste and other socio-cultural differences. Four of the more populated states in India contribute to nearly 60% of the country’s total burden of under-five deaths (Uttar Pradesh, 0.35 million; Bihar, 0.15 million; Madhya Pradesh, 0.13 million; and Rajasthan, 0.1 million). Similarly, the under-five mortality rate (U5MR) for girls is 1.3 times higher than boys. Rural U5MR is 1.6 times higher than the urban.
Health status can be widely different between states, and differences can remain hidden behind national averages. For example, the under-five mortality rate per 1,000 live births in rural Uttar Pradesh is 82, compared with Bihar (60), Tamil Nadu (31) and Kerala (8).
Similarly, the care-seeking behaviour for pneumonia varies widely in rural areas (Uttar Pradesh, 69.7%; Bihar, 60.1%; Tamil Nadu, 81.1%; and Kerala, 89.9%). UP and Bihar are the two states with the lowest allocations for health, with Kerala and Tamil Nadu being some of the highest. Both Kerala and Tamil Nadu also invest in primary health care both in rural and urban areas and under-five mortality figures are not very different in rural and urban areas, whereas in UP and Bihar there are big differences. Governance structures and systems are also better developed in states such as Kerala and Tamil Nadu, enabling efficiencies in planning, budgeting, and expenditure.
Low funding at local and national levels
A lack of state level investment in health is compounded by a chronic low investment in health at the national level. Despite the launch of the NHM, there has been a distinct lack of correlation between policies and resource allocations. Government health expenditure was as low as 1% of GDP in 2004, and rose to just 1.4% in 2014, despite GDP growth rate having been at 8.4. Per capita expenditure on health remains low at $23 per head in 2014. Out of pocket payments as a percentage of total expenditure on health was at 67.9% in 2004, and despite all the new policies and increased investment in health, fell to just 62% in 2014.
Since the launch of the NHM there has been a slow but steady increase in government expenditure on health and in 2014 was 1.4% of GDP at a time when the GDP growth rate was 8.4%. Investment in health has increased marginally but steadily, although India’s GDP growth rate fell to 6% in 2016 and now sits at 7% – a clear indication that the investment in health is not a direct consequence of GDP growth rates.
Equity targeted programmes within the NHM may have contributed to shaping health plans and channelling resources to areas of need, but considering the extent of the need, India needs to increase its political will to invest in health and accelerate their investment to at least 5% of their GDP if they are to make any inroads into addressing their weak health system which is plagued by socio, economic, political, and state level disparities.
So why is the U5MR du pneumonia falling?
Although certain states perform better than others, there is no clear single explanation for the decrease in U5MR due to pneumonia. The various equity targeted health policies, introduction of IMNCI and F-IMNCI training packages for ANMs, staff nurses and doctors, investment in a new cadre of community level heath workers with mandate to use antibiotics at the community level, inclusion of HiB3 and improving routine immunisation coverage, nationwide improvement in breast feeding rates for children under 6 months ( which has increased gradually from 46.4% in 2005-6 to 55% in 2015-16), an improved public food distribution system contributing to improved nutrition levels, along with a livelihood protection scheme which targets women – all these working in tandem have contributed to reducing the U5MR due to pneumonia in India. All this despite minimal increases in heath expenditure.
Read our featured pneumonia country briefings and our new report, Fighting for Breath.