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.
Sierra Leone’s Reproductive, Newborn and Child Health Policy 2011 defined pneumonia as the most common cause of under-five mortality, and responsible for 24% of all under-five deaths. WHO data shows that there were 6,630 under-five deaths in 2004, falling to 3,705 in 2015 – a 43% drop over the past 10 years, with pneumonia accounting for just 14% of all under-five mortality in 2015.
Recovering from war
The eleven-year civil war in Sierra Leone ended in 2002, at which point public health expenditure was as low as 3% of the country’s GDP. The impact of the civil war was further compounded by low investment in health, leading to severe shortages of health workers, as well as infrastructure and equipment, resulting in very high maternal and infant mortality rates.
Just over a decade since the civil war, the country was faced with the EVD crisis in 2014-15. These crises have resulted in a severe shortage of health workers, with just four doctors per 100,000 population. Sierra Leone also has one of the world’s lowest skilled health professional density at 1.9 per 10,000 people.
Although Sierra Leone does not have a specific pneumonia policy, several guidelines have been put in place by the government to address the challenge posed by pneumonia and its contribution to the disease burden in Sierra Leone.
Falling investment in health
The government launched the Free Health Care Initiative (FHCI) in 2010 and abolished user fees for pregnant & lactating women and under-fives. But this commitment has not been supported with adequate resources, with public health expenditure fluctuating between 2.8% of the GDP in 2003 to 1.9% in 2014. Per capita government expenditure on health was $46 in 2010 and is at $15 in 2014.
In the same period, external resources for health as a percentage of total expenditure on health rose from 13.3% in 2010, peaked at 32.1% in 2013 and has since fallen to 17.1% in 2014. Out of pocket payments have risen from 71.3% of total health expenditure in 2002 to 80% in 2008 and has steadily dropped to 61% in 2014, which is still much higher than the WHO recommended rate of 15-20%.
Sierra Leone’s national systems suffer from chronic inefficiencies and leakages within the system. In 2012, GAVI conducted a Financial Management Assessment which unearthed the misuse of $523,303 of the health system strengthening tranche due to weak financial systems.
With donor confidence on the ebb, it is important for Sierra Leone to increase its tax based domestic financing for health. This can prove quite daunting for a country which lost 14% of its GDP in 2011 alone to tax exemptions. There has been an average $200 million annual loss between 2010-12 just from tax exemptions on goods and services granted to companies, non-governmental organisations, and embassies.
U5MR falling against all odds
Despite these challenges, and the low levels of resourcing for health, Sierra Leone has managed to almost halve the number of deaths due to pneumonia since 2004 with the disease no longer being the biggest killer of under-fives. This could be attributed to the FHCI, which ensures that pregnant women and children under five have access to free health care, despite the inefficiencies and lack of resourcing which plague the initiative.
The FHCI has also invested in community health workers who are the first line of care for pneumonia. Sierra Leone has more than 15,000 Community Health Workers (CHW) who are trained to diagnose and treat pneumonia at the community level using antibiotics, and this has enabled care seeking behaviour for pneumonia to increase from 48% in 2005 to 72% in 2013.
Hib 3 and PCV were rolled out in 2007 and 2011 respectively and coverage is high for both at 84% in 2016. Another reason Sierra Leone has been successful in reducing pneumonia deaths could be attributed to the improving exclusive breastfeeding rates in the country which has risen from 8% in 2005 to 59% in 2014.
Predictable, stable support
A weak health system, which has been further weakened by the EVD crisis, now needs predictable external support to rebuild and strengthen its national health system if it is to maintain the momentum they have achieved in reducing deaths due to pneumonia. At a time like this, external support seems to be falling quite dramatically. This dangerous trend needs to be reversed if Sierra Leone is to continue combatting pneumonia and making progress towards SDG3.
Read our featured pneumonia country briefings and our new report, Fighting for Breath.