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 Nigeria, pneumonia has replaced malaria as the number one killer of children under five, claiming 18% of all under-five deaths. According to the WHO, there were 148,772 under-five deaths due to pneumonia in Nigeria in 2004, falling slightly to 132,556 in 2015.
Meeting pneumonia head on
Several policies and guidelines have been put in place by the Nigerian government to address the challenge posed by pneumonia. The strong policy environment has ensured that government health expenditure – which was just 1.4% of the GDP in 2004 – has risen to 3.5% in 2014 according to the National Health Accounts. Per capita expenditure on health has also risen sharply since 2004 from $45 to $118 in 2014. Having said this, government expenditure as a percentage of total health expenditure has fallen since 2004, from 33% to 25% in 2014, with out of pocket payments increasing from 64% of total health expenditure in 2004 to 69% in 2014.
Why slow progress?
There are several reasons why, despite the increased investment in health, Nigeria has not been able to make significant progress in reducing the under-five mortality rate (U5MR) due to pneumonia. One of the fundamental challenges against policy implementation is the governance structure for health in Nigeria. Nigeria is a Federal Republic with 36 states, 774 Local Governments and the Federal Government. All three areas have responsibility for health, which is on the concurrent legislative list. This means that policies at the Federal level are not necessarily implemented at the sub-national level unless the sub-national government is interested, resulting in most policies not being implemented at the state level.
To compound this problem, there is legislation to ensure that Federal grants to the States cannot be earmarked in any way, not even for health. This makes it doubly difficult for the Federal government to ensure the implementation and resourcing of any health plan at the state level, with dire consequences. According to the 2013 DHS, the U5MR per 1,000 live births in the North West was 185, in the North East 160, and the South South 91. 54.2% of children received antibiotics to treat pneumonia in the South South, compared with 36.2% in the North West, and 35.1% in the North East. With health infrastructure being so limited in Nigeria, it is critical that sustained, predictable funding is directed to the sector to try and build the health system, especially at the primary health care level.
The importance of accountability
One of the biggest challenges to policy implementation remains weak governance and accountability systems within the health sector. In 2015, GAVI’s Cash Programme Audit (CPA) identified a misuse of US$ 2.2 million which was eventually returned by the government of Nigeria. This is just one example of severe leakages and fiscal irresponsibility within the system and can help us understand why the per capita expenditure for health, while seeming high, may not be contributing to building the health system. It is important for Nigeria to back its policies and resourcing plans with a serious revamping and revitalising of its governance systems and ensuring more civil society oversight and involvement in accountability processes.
Benefit of a vaccine price freeze
As Nigeria is a GAVI graduating country, GSK has committed to a ten-year price freeze on vaccines for pneumonia, enabling the country to reduce U5MR due to the disease. It is also critical that the country harmonises policy formulation, implementation and resourcing at the National and sub-national levels, and addresses leakages at all levels.
Fortunately, the Federal Government is in the process of rebuilding and revitalising Primary Health Care Centres in Nigeria as part of the Primary Health Care Under one Roof (PHCUOR) initiative. It is important to ensure that pneumonia management and care is part of this comprehensive plan and will include integrated strategies such as IMCI and ICCM.
Read our featured pneumonia country briefings and our new report, Fighting for Breath.