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Community sites informing programmes and policies

Community sites informing programmes and policies. Anthony Costello UCL Centre for International Health and Development. India IMR trends. Supply. Technical. Behavioural. Interventions e.g drugs, supplements, vaccines Knowledge and skills QOC/MIS/Facilities Referral. Motivation

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Community sites informing programmes and policies

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  1. Community sites informing programmes and policies Anthony Costello UCL Centre for International Health and Development

  2. India IMR trends

  3. Supply Technical Behavioural Interventions e.g drugs, supplements, vaccines Knowledge and skills QOC/MIS/Facilities Referral Motivation Leadership Work culture Communication Governance HH or community Environmental Demand Knowledge, beliefs, and culture Decision-making Delays in seeking care Social capital/networks Economic access/equity Vectors Water and sanitation Pollution Pesticides Slum transfer Parks and play

  4. Supply Urban 80% hospital deliveries Technical Quality of Care Behavioural Appreciative inquiry Demand Governance HH or community Environmental

  5. Supply Rural 15% hospital deliveries Technical Quality of Care Behavioural Appreciative inquiry Governance HH or community Agents of change Womens groups Traditional health systems Equity Demand Environmental Vectors Water

  6. Efficacy and effectiveness Antibiotics for neonatal sepsis 95% efficacy Coverage 60% Diagnosis 40% Implementation 50% Compliance 50% Effectiveness 0.95 x 0.6 x 0.4 x 0.5 x 0.5% Overall = 6%

  7. Principles of essential newborn care • Air/breathing/resuscitation • Warmth • Early breastfeeding • Hygiene • Keep with mother • Treat illness and infection promptly

  8. MMR reduction, England and Wales

  9. Principles of essential obstetric care • Antenatal care • Hygiene • Birth preparedness to avoid delays • Skilled attendant • Access to emergency obstetric care • Postnatal care

  10. Principles of comprehensive obstetric care • Prevent malaria, malnutrition, anemia etc • Safe abortion • Treat infection and shock promptly • Prevent and treat haemorrhage • Prevent and treat eclampsia • Treat obstructed labour and ruptured uterus by caesarean section • Retained placenta

  11. On the road

  12. Maternity access

  13. How do we know whether our policies and programmes are working?

  14. Wisdom of elders? • NO. WE NEED EVIDENCE, DATA • Because it has worked somewhere else? • BUT POPULATION MAY BE DIFFERENT • Before and after study? • YES, OK, BUT CONFOUNDERS • Control area vs intervention area? • BETTER • Randomised controlled trial? • BEST, BUT NOT ALWAYS FEASIBLE

  15. Supply Technical Behavioural Interventions e.g drugs, supplements, vaccines Knowledge and skills QOC/MIS/Facilities Referral Motivation Leadership Work culture Communication BANG Governance HH or community Environmental Demand Knowledge, beliefs, and culture Decision-making Delays in seeking care Social capital/networks Economic access/equity Vectors Water and sanitation Pollution Pesticides Slum transfer Parks and play

  16. 60% fall in NMR TBA VHW

  17. Supply Technical Behavioural Interventions e.g drugs, supplements, vaccines Knowledge and skills QOC/MIS/Facilities Referral Motivation Leadership Work culture Communication Micronutrients In pregnancy Governance HH or community Environmental Demand Knowledge, beliefs, and culture Decision-making Delays in seeking care Social capital/networks Economic access/equity Vectors Water and sanitation Pollution Pesticides Slum transfer Parks and play

  18. MIRA Janakpur, Nepal Double-blind randomized controlled trial of the effects of antenatal multiple micronutrient supplementation on birth weight and gestational duration in Nepal David Osrin, Anjana Vaidya, Yagya Shrestha, Ram Baniya, Dharma Manandhar, Ramesh Adhikari, Suzanne Filteau, Andrew Tomkins, Anthony Costello

  19. Control Intervention Iron 60 mg Folic acid 400 mcg Vitamin A 800 mcg Vitamin B1 1.4 mg Vitamin B2 1.4 mg Vitamin B6 1.9 mg Vitamin B12 2.6 mcg Vitamin C 70 mg Vitamin D 5 mcg Vitamin E 10 mg Niacin 18 mg Folic acid 400 mcg Iron 30 mg Zinc 15 mg Copper 2 mg Selenium 65 mcg Iodine 150 mcg

  20. 77g increase in birth weight

  21. Combined mortality Janakpur and Sarlahi trials, Nepal

  22. Why community effectiveness evaluation is important • Gives an idea of baseline conditions which may not be known • Measures the true impact of an intervention • Detects unexpected benefits • Detects unexpected risks

  23. Supply Technical Behavioural Interventions e.g drugs, supplements, vaccines Knowledge and skills QOC/MIS/Facilities Referral Motivation Leadership Work culture Communication Appreciative Inquiry Governance HH or community Environmental Demand Knowledge, beliefs, and culture Decision-making Delays in seeking care Social capital/networks Economic access/equity Vectors Water and sanitation Pollution Pesticides Slum transfer Parks and play

  24. Appreciating what staff (and mothers) do in difficult circumstances

  25. Supply Technical Behavioural Interventions e.g drugs, supplements, vaccines Knowledge and skills QOC/MIS/Facilities Referral Motivation Leadership Work culture Communication Governance HH or community Environmental Demand Knowledge, beliefs, and culture Decision-making Delays in seeking care Social capital/networks Economic access/equity Vectors Water and sanitation Pollution Pesticides Slum transfer Parks and play Women’s Agency

  26. Agents of change for demand side intervention Dr T Sundararaman from State Health Resource Centre, Chhattisgarh Activities of mitanins

  27. Cluster randomised controlled trial MIRA Makwanpur Study The effects of a participatory intervention involving women’s groups on birth outcomes in rural Nepal (Lancet 2004) MIRA Dharma Manandhar, Bhim Shrestha, Kirti Tumbahangphe, Suresh Tamang, Dej Shrestha, Susma Thapa, Bidur Thapa, Aman Sen, Shyam Shrestha, Jyoti Shrestha, Madan Manandhar ICH David Osrin, Natasha Mesko, Joanna Morrison, Jo Borghi, Angie Wade, Hilary Standing, Anthony Costello

  28. Supply Demand

  29. The intervention 1 local woman facilitator per cluster Not a health worker 7000 population, 60 sq km 9 monthly women’s groups Only 8% coverage of target married women

  30. Problem Identification Participatory evaluation Planning together Implementation Year 2

  31. Mortality rate comparison Reductions in maternal and newborn mortality larger than expected

  32. Cost • $110 per group per year plus $203 for supervision • $0.75 per capita • Cost per life year saved: $211 but for expansion could fall to $138. • Borghi et al, Lancet 2005

  33. Amplification One woman facilitator 8% MWRA in groups 37% newly pregnant women in groups ?% non-group pregnant women

  34. Scepticism about findings Will it work elsewhere? Need several studies to change policy

  35. Bangladesh

  36. India, Jharkand

  37. India, Mumbai

  38. Nepal MIRA Dhanusha trial

  39. Malawi Lancet Sept 30 2006, Rosato, Mwansambo et al.

  40. Why community sites to study effectiveness evaluation are important • Data is powerful for advocacy: “every child counts so count every child” • Costs and scaleability • Can generate political will and commitment, and try to promote accountability • Is unethical not to evaluate what we do

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