Ampasimanjeva — Even after days on an antibiotic regime, three-month-old Jean Marie Anselme struggles to breathe and eat at the Fondation Médical d'Ampasimanjeva, a hospital in Vatovavy-Fitovinany Region, in southeastern Madagascar.
Clement Ranoeliharivelo, a doctor at the hospital, told IRIN Jean Marie was suffering from pneumonia; it was the fourth such case he had treated in a week. "One of them died. Sometimes the same child comes in twice in a month," he said.
"Cases increase during the rainy season [from November to April] as the air becomes damp, and mothers are often too ignorant or negligent to treat children when they have a cold," he said.
In Madagascar, pneumonia is responsible for 21 percent of deaths among children under five years old - making it the leading cause of death for this age group - followed by malaria, which causes 20 percent of under-five deaths, and diarrhoea, which causes 17 percent.
According to the Global Alliance for Vaccines and Immunization (GAVI), pneumonia and diarrhoea are responsible for about 40 percent of deaths globally among children under age five.
The recent introduction of a vaccine to protect against pneumococcal disease, the leading cause of severe childhood pneumonia, is attempting to reduce the thousands of child deaths that occur every year in Madagascar.
"We try to prevent and treat all three diseases [pneumonia, malaria and diarrhoea]. Education for behaviour change is important. To prevent pneumonia we tell mothers to keep children warm when they are sick and keep them out of stuffy places, and we strive for an 80 percent coverage nationwide of the routine vaccination schedule," Paul Ngwakum, head of the UN Children's Fund's (UNICEF) Madagascar child survival and development unit, told IRIN.
"The pneumococcal germ lives in the body, and when there is stress or malnutrition or other risk factors, it can become pathological. The germ can also be transmitted directly from person to person through close contact via respiratory droplets," Ngwakum said.
"As the age of the child goes up, the mortality rate goes down, because as the child gets older, it builds up more resistance. So with our vaccinations, we concentrate on babies before their first birthday."
Yet there are major stumbling blocks for the vaccination programme: the country's poor infrastructure and its high poverty rates.
Poverty rates in Madagascar have been on the rise since 2009, when President Marc Ravalomanana was deposed in a coup d'etat. More than three quarters of the country's 20 million people now live on less than US$1 a day, according to government figures - up from 68 percent before the political crisis.
"Patients often can't come here because of poverty. They [subsistence farmers] have to wait for the fruit to be ripe and collectors come buy it and give them some money. That's when they can afford the transportation to the hospital, provisions for their stay here and the 700 ariary [$0.30] fee," Ranoeliharivelo said.
In 2008, UNICEF set a five-year goal of reducing under-five mortality by 30 percent, but the political crisis has, in part, derailed this target; the international community imposed sanctions on the donor-dependent country in response to the coup d'etat. The 30 percent target remains, but there is little optimism about achieving it.
"In some places, the health centre is closed due to lack of staff. Consequently, there is no way to administer vaccines to children. We also need a functioning cold chain, and some health centres have a refrigerator but no more kerosene. The whole health sector struggles with reduced funding, so even if the health centre is up and functioning, there is often no money for community outreach," Ngwakum said.
Government health statistics show that in 2011, some 83,171 Malagasy children received no vaccinations for any diseases. In the first quarter of 2012, this number rose to 191,435.
Reaching remote areas
"In many places, there is no geographical access. If the vaccines aren't delivered there, it means people have to pay [for] transportation to come and get it. We try to go to all these villages," Ngwakum said.
Twice a year, the health department and UNICEF conduct Mother and Child Health Weeks, during which they dispatch 2,500 teams of health workers and 20,000 volunteers to 22 regions of the island state.
Child survival packages are distributed; these include supplements such as vitamin A, as well as essential vaccines - to which the pneumococcal vaccinations has been added. In November 2012, the pneumococcal vaccine was administered in the targeted regions in Madagascar, reaching 60 percent of children 12 months or younger.
"In places where health centres are closed, the children still need healthcare. We reach them through the Mother and Child Weeks. If we didn't, there would be nothing," Ngwakum told IRIN.
UNICEF also supports the Reaching Every District (RED) initiative, which accesses other, more remote, areas. Still, many children have yet to be reached.
"There are still many unreached pockets. Some districts have an 80 percent coverage on the map, but this is an average. There are still some problems," Ngwakum continued.
Additionally, a $29 million donation from the European Union, under the aegis of Madagascar's PASSOBA programme (projet d'appui aux secteurs sociaux de base -Santé), will increase health coverage through the recruitment of staff and the re-opening of health centres in five regions.
[This report does not necessarily reflect the views of the United Nations.]