Could devolving pneumonia treatment to local health centres reduce mortality in developing countries?

Even though paediatric deaths due to pneumonia have decreased, they remain a leading cause of death in children under the age of 5 years. This is despite the moderate to high coverage of vaccines, implementation of the Integrated Management of Childhood Illness guidelines, released by the World Health Organization in 2017, and improved nutrition.1 The relative decline in deaths due to pneumonia is less than the reductions for other childhood diseases, and severe pneumonia often needs inpatient treatment by skilled healthcare staff. In this issue of Acta Paediatrica, Tariku et al report how 5700 families sought, and received, care by analysing 430 health facilities in Ethiopia for suspected pneumonia, together with the prevention strategies they provided.2 They found that the caregivers had low awareness of suspected pneumonia treatment and that their use of these healthcare services were low. The study also found that some healthcare staff working in the community were not knowledgeable about lower respiratory tract infections. The authors recommended that strengthening primary healthcare, including immunisation, and enhancing the use of services were critical for further reductions in pneumonia mortality. Carrying out studies on the use of health services is very important. However, does such essential research information lead to policy changes and improved health care? Researchers often believe it does, but evidence shows that implementing research in real-life practice can be difficult. Many low-income countries experience poverty and high disease burdens and this often leads to a vicious cycle, where poverty aggravates the disease burden and people with heavy disease burdens exacerbate poverty. Research that produces sound evidence that informs local, regional and national policies is essential. In turn, those findings have the potential to transform lives for the better. Public policies that seek to address these challenges will only work if the technical and political choices made by decision-makers are informed by the best available evidence. While policy decisions may result in changes in legislation, this mainly occurs when decisions about resource allocations, regulations and new strategies are made. The people making these decisions are most frequently government officials and institutional leaders at local, regional and national levels.3 Vaccination programs, especially for pneumococcal disease, are important. Unfortunately, only one-third (33%) of children are fully vaccinated in Ethiopia, 40 years after it introduced its expanded immunisation programme. In addition, coverage is unevenly distributed across geographical areas and is affected by wealth and educational status.4 In 2005, an editorial in Tropical Medicine and International Health discussed the use of studies that identified risk factors for delays on tuberculosis treatment.5 A large number of studies had been carried out on this and they all pointed out risk factors related to both the patient and the healthcare system. The rationale for these recommendations was that the delayed diagnosis and treatment of pulmonary tuberculosis increased transmission, because patients were contagious until effective chemotherapy was started. Published research often advocates that educating the public about tuberculosis could reduce delays and increase case detection. Unfortunately, there is limited information that such information works on its own. Nevertheless, there is some evidence that enhancing qualified human resources improves the health infrastructure and the skills of healthcare workers and improves access to essential services that could improve patient management. Even very impoverished communities with high rates of illiteracy will use health services if they are good quality, affordable and accessible. In a large intervention study in southern Ethiopia, we improved access to good-quality services to mothers delivering babies near their homes. We were able to reduce maternal deaths by about 60%, by upgrading rural health centres so that they were able to carry out Caesarean sections and improve basic emergency obstetric care.6 This was achieved by a concept that is widely practiced in child health care, namely that non-clinical physicians were able to partially replace the functions of physicians. Could a similar strategy be used to improve the management of severe pneumonia? A more detailed mapping of the support that health systems provide for managing severe pneumonia in southern Ethiopia found that less than one-third of health centres and health posts received supervision from the local and regional health authorities. Antibiotics were not always available and vaccination services were suboptimal. The study concluded that there was room to improve the support that the health system received, by integrating the management of neonatal and childhood illness. It was stated that this could be achieved through supply chain management and improving the knowledge of health workers involved in managing severe pneumonia.7 In a follow-up study on the same institutions, adding pulse oximetry to the WHO Integrated Management of Childhood Illness algorithm significantly increased the number of diagnosed severe pneumonia cases in health centres. This step could help to reduce childhood mortality from hypoxaemia.8 Tariku et al2 agree with the findings of Hailemariam et al7 and Tesfaye et al,8 which found that children with severe pneumonia were referred for management at a higher level.2, 7, 8 Unfortunately, only about half of the children in the Tesfaye et al8 study went to the hospital. The reasons are for this were complex, but distance and cost could explain lack of compliance with such recommendations.8 Interventions that would improve the compliance of patients could be good-quality care, combined with decentralising the management of severe childhood pneumonia treatment to health centres. These are often located near patients’ homes and may need trained staff, pulse-oximeters, antibiotics and oxygen therapy. However, the case fatality rate for hypoxemic pneumonia is still high, despite the provision of oxygen, antibiotics and treatment guidelines. Methods for delivering continuous positive airway pressure are available, which are simple to use, safe and relatively inexpensive. But more research is needed on the implementation, cost and effectiveness of this treatment for the management of severe pneumonia at health centres and rural hospitals in low-income countries.9 To ensure better implementation of research findings, the organisations that fund research need to stress the importance of involving patients or the public in research. Should this additional focus be the future norm for surveys in countries such as Ethiopia? We already have guidance on patient and public involvement, thanks to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.10 So, should the funding organisations and ethical research committees be more concerned about how the results from surveys are implemented? What is clear is that we need more studies like the Tariku et al research published in this issue,2 also because the coronavirus disease COVID-19 pandemic and resultant socioeconomic crisis could further worsen the delivery of child health services in Africa. The author has no conflicts of interest to declare. Bernt Lindtjørn