Bottlenecks, barriers, and solutions: results from multicountry consultations focused on reduction of childhood pneumonia and diarrhoea deaths

Summary

Millions of children still die unnecessarily from pneumonia and diarrhoea, mainly in resource-poor settings. A series of collaborative consultations and workshops involving several hundred academic, public health, governmental and private sector stakeholders were convened to identify the key barriers to progress and to issue recommendations. Bottlenecks impairing access to commodities included antiquated supply management systems, insufficient funding for drugs, inadequate knowledge about interventions by clients and providers, health worker shortages, poor support for training or retention of health workers, and a failure to convert national policies into action plans. Key programmatic barriers included an absence of effective programme coordination between and within partner organisations, scarce financial resources, inadequate training and support for health workers, sporadic availability of key commodities, and suboptimal programme management. However, these problems are solvable. Advocacy could help to mobilise needed resources, raise awareness, and prioritise childhood pneumonia and diarrhoea deaths in the coming decade.

Introduction

In 1990, roughly 11·9 million children died, mostly in low-income and middle-income countries. 20 years later, this number had fallen by 40% to about 6·9 million per year.1, 2 Both then and now, most deaths in the post-neonatal period are due to pneumonia and diarrhoea (see the first paper in this Series).³ Although the reduction in child deaths falls short of the 2015 Millennium Development Goal 4 target for a two-thirds reduction in children younger than 5 years (under-5 mortality),⁴ it is still a major achievement that the global public health community should celebrate.

Targeted investments in public health played a major part, as the case of Bangladesh shows (panel 1). The past decade saw unprecedented amounts of investments in global public health, both from donor nations (in the form of direct contributions or channelled through the Global Fund to Fight AIDS, Tuberculosis and Malaria), and private philanthropic organisations.⁵

However, unfortunate truths remain. Economic development was a key factor in reducing child mortality, and the burden of pneumonia and diarrhoea mortality is increasingly concentrated in resource-poor settings.³ In 1990, childhood mortality rates were highest in sub-Saharan Africa, which is still the case now.² In fact, childhood mortality rates in sub-Saharan Africa have stagnated over the past decade, and have even increased in some countries.⁶ Yet, the basic elements necessary to reduce childhood deaths from pneumonia and diarrhoea are well known. The treatments (antibiotics for pneumonia, oral rehydration solutions, and zinc) are safe and effective; off-patent; inexpensive to manufacture; require no cold chains; only need to be taken episodically and for short periods; and are inexpensive, costing pennies per treatment course.7, 8, 9, 10 However, scarcely half of children with severe acute pneumonia receive antibiotics; and of children with acute diarrhoea, only a third receive oral rehydration solution and less than 1% receive zinc (table 1).²

To improve this situation, a series of collaborative exercises with key stakeholders were conducted to identify barriers to reducing childhood pneumonia and diarrhoea deaths and recommend solutions¹¹ (panel 2). We present the main lessons learned and address the most important bottlenecks to the use of key commodities for the prevention or management of pneumonia and diarrhoea; the key programmatic, policy, and resource barriers impeding progress; and suggest how we can move forward.

Key messages

• Pneumonia and diarrhoea are the leading causes of preventable deaths for children living in the world's poorest countries

• A series of consultations with several hundred public health practitioners working at the front lines of child survival in target countries were held to identify bottlenecks and key barriers to scaling up of evidence-based interventions to reduce pneumonia and diarrhoea mortality, and recommend tangible solutions

• Key barriers included:

  • Absence of national coordination within ministries and other stakeholders to deliver interventions

  • Insufficient financial resources

  • Inadequate training and support for health workers

  • Poor systems for monitoring and assessment of key programmatic indicators

  • Sporadic availability of key commodities

• Key recommendations included:

  • Improve coordination between various groups working on preventive and treatment interventions to control pneumonia and diarrhoea

  • Substantially increase resources for child survival programmes, with an emphasis on pneumonia and diarrhoea control efforts

  • Enhance efforts to attract, train, and retain a competent work force of caregivers

  • Invest in better systems for harmonisation of the collection of essential programmatic indicators, and ensure that this information is shared throughout the system

  • Strengthen supply systems that deliver essential commodities