Evidence for scale: a partnership to tackle pneumonia in Nigeria

A new, comprehensive study – carried out by Save the Children in collaboration with UCL’s Institute for Global Health, University College Hospital, Ibadan and GSK – presents far-reaching evidence that could inform a major policy push to bend the curve of paediatric pneumonia mortality in Nigeria, the country with the largest number of child deaths from the disease. The findings – our most significant contribution to date to evidence on the burden of pneumonia – have just been published in a Special Issue of the Journal of Paediatric Pulmonology,

This blog gives an overview of the findings of the five papers from our partnership research project (as well as links to the full articles).

Save the Children has helped instigate a global push to tackle pneumonia, the biggest infectious killer of children. The jewel in the crown of our efforts to eliminate preventable child deaths from pneumonia is our INSPIRING programme in Nigeria. A £7.5 million project supported by GSK and designed to test innovative and scalable approaches in two states, Jigawa and Lagos, it has a bold ambition: to provide extensive and directly applicable evidence of what works to reduce the burden of childhood pneumonia in two contexts that, taken together, are representative of Nigeria’s diversity.

Our wide-ranging research partnership has looked at the multiple barriers to reducing pneumonia-led child mortality in Nigeria:

• challenges in understanding the actual burden of disease
• health system bottlenecks
• behavioural and gendered barriers to care-seeking
• the political economy of child health.

It has also explored the factors behind Nigeria’s leadership in developing the world’s first ever Pneumonia Control Strategy, to which we turn first.

Every Breath Counts in Nigeria

Nigeria is the first country where the Every Breath Counts coalition (EBCC), a public–private partnership to end preventable child pneumonia deaths, has really come to life to drive meaningful change. In January 2020, at the Global Forum on Childhood Pneumonia in Barcelona, the Nigerian Federal Minister for Health launched the country’s first-ever Pneumonia Control Strategy.

Our commentary on this process, co-authored with Leith Greenslade, co-ordinator of the EBCC, sets out three key lessons:

1. The Pneumonia Control Strategy elevated the status of childhood pneumonia as a key public health challenge in Nigeria without undermining integrated, primary healthcare approaches such as integrated community care management – or ICCM.
2. The process to develop the strategy improved cross-sectoral and inter-ministerial collaboration for child health across different levels of government in Nigeria.
3. The experience in Nigeria highlights the importance of taking a data-driven approach that puts the most vulnerable populations of children first.

Read the full paper.

The political economy of pneumonia in Nigeria

This article looks at stakeholders’ perspectives on what is preventing Nigeria from making a dent in pneumonia-led mortality. The key findings are:

1. Pneumonia is Nigeria’s biggest cause of child mortality and yet, in comparison with other, less lethal diseases, it is characterised by a chronic and systemic lack of social and political attention. A symptom of this is the absence of a universally agreed set of policies and guidelines to tackle childhood pneumonia.
2. Efforts to tackle pneumonia in Nigeria to date have been dispersed, uncoordinated and largely driven by donors. Along with a poorly resourced health system, a plurality of healthcare providers and low levels of awareness in communities, this has hampered progress.
3. The top priorities for pneumonia control according to stakeholders interviewed in Abuja, Lagos and Jigawa are to:
   • increase caregivers’ knowledge of this poorly understood disease
   • train health workers on pneumonia diagnostic and treatment
   • expand access to antibiotics, particularly amoxicillin
   • improve access to pulse oximetry for improved diagnostic and referrals of severely ill children.
4. The lack of healthcare financing in Nigeria – 0.5% of gross domestic product and 5% of national budgets are spent on health – is seen to have a particularly acute impact on primary healthcare and community health systems, which are essential in reducing the burden of pneumonia.
5. Nigeria‘s pioneering work in developing a national pneumonia control strategy is a key milestone in addressing the challenges of coordination, multiplicity of policies and absence of clear guidelines.

Read the full paper.

The burden of disease in Nigeria

The true burden of pneumonia is not as well understood as we think, especially in low-income countries like Nigeria, where occurrences of the disease are seldom recorded, often misdiagnosed and deaths rarely subject to a verbal autopsy. This literature review uncovered not just what is known but, critically, what is still not known about the true burden of disease in the states of Lagos and Jigawa:

1. We cannot tackle what we cannot see! There are clear evidence gaps around the burden of paediatric pneumonia in Nigeria, as well as challenges with the interpretation of existing household survey data. For instance, household surveys – which form the basis for estimates of pneumonia prevalence – are not designed to distinguish pneumonia from wider acute respiratory infections (ARIs), a common proxy for pneumonia, which probably include common colds.
2. The child mortality rate from ARI in Nigeria is estimated at 19.4% of all child deaths. However, available data at state level for Lagos and Jigawa is much less precise and is not stratified by age.
3. More strikingly, there is a complete lack of data in these two regions on
   • pneumonia incidence (number of new cases recorded)
   • case‐fatality rates (percentage of sick children who die from the illness)
   • the severity of pneumonia cases.
4. This major evidence gap could be partly due to the absence of pulse oximeters (diagnostic tools that measure oxygen saturation) in the healthcare system. Whatever the cause, this suggests significant underreporting of pneumonia in Lagos and Jigawa, as in the rest of Nigeria.
5. Investments in innovative data systems are urgently needed for more reliable routine health information systems in Nigeria to provide reliable, timely data on the clinical pneumonia.

Read the full paper.

The bottlenecks in the Nigerian health system

The clinical and non-clinical interventions needed to prevent and treat pneumonia are well-known. The implementation of standard World Health Organization guidelines (which include immunisation with HiB and pneumococcal vaccines, exclusive breastfeeding for the first six months, a course of antibiotics to treat detected cases, and oxygen therapy for hypoxemic children), have contributed to considerable reductions in pneumonia mortality in many parts of the world. That Nigeria has achieved so little progress suggests major bottlenecks in the health system that prevent large swathes of the population from accessing these essential services. Key findings of the paper, based on a mixed-method study in Lagos and Jigawa, are:

1. While internationally accepted guidelines to manage pneumonia exist and have been in place for three decades, health workers’ knowledge of these guidelines is extremely poor, and only just over a third of healthcare providers in Lagos and Jigawa had been trained on them. Just 9% of the health workers interviewed could recognise the signs of anaemia – a risk factor for severe pneumonia – and 21% knew what advice should be given to caregivers of children with pneumonia.
2. Health facilities sorely lack essential and lifesaving equipment to diagnose and treat pneumonia: just a quarter of health centres in Jigawa were equipped with functional pulse oximeters and one major hospital in the state, despite being a referral hospital for severe pneumonia, lacked both oximeters and oxygen equipment.
3. The very low numbers of pneumonia cases seen in primary health centres does not reflect the true burden of the disease. They also suggest parents of children sick with pneumonia do not go to primary care but wait until their child is very sick and go straight to the hospital. Large numbers of episodes of pneumonia bypass primary healthcare or bypass the health system entirely.

Read the full paper.

The perceptions and behaviours of Nigerian communities in relation to pneumonia

One thing is clear: to beat the world’s and Nigeria’s biggest infectious killer of children, we cannot count on clinical, curative interventions alone. A key part of the solution resides in the capacity of parents and communities to:

• adopt lifesaving preventive practices (e.g., vaccination, exclusive breastfeeding)
• recognise the signs of pneumonia early on
• seek timely and appropriate care when a child shows signs of the disease.

This paper explores the behavioural barriers to effective care seeking for children with pneumonia in Lagos and Jigawa. Its key findings are:

1. Gendered dynamics are clearly at play: while women are generally seen as responsible for identifying the illness and notifying their husbands, the mobilisation of financial resources to seek care is generally within the husband’s purview (although joint decision-making is also quite common). This suggests that gendered social norms prevent quick care-seeking. Work is therefore needed to change social norms and empower women to make decisions.
2. Many parents can’t recognise the symptoms of pneumonia, and their knowledge of the risk factors is also quite low: many automatically assume that pneumonia results mostly from exposure to cold air.
3. The cost of healthcare is a major barrier to using health services, both in Lagos, where private providers are often the first point of care, and in Jigawa, where essential drugs must be purchased from pharmacies. Nigeria’s new Community-Based Health Insurance scheme could help alleviate come of this hardship but low uptake to date means its impact so far has been limited.

Read the full paper.

What’s next?

Save the Children’s INSPIRING programme has been designed to find cost-effective, evidence-driven solutions over the next three years to address many of the challenges cited above. Further evidence of impact and scalability will be published in the coming years. Watch this space!