Outline

1. A Systematic Review of the Effectiveness of Community-Based Primary Health Care in Improving Child Health Sponsored by the Working Group on CBPHC of the International Health Section of APHA in collaboration with UNICEF, WHO, the World Bank and with support from Future Generations

2. Outline • Describe the review and methods • A few observations about specific interventions • Evidence concerning integrated approaches • Cross-cutting themes: scaling up/CHWs • Findings, recommendations and conclusions

3. Study Questions • How strong is the evidence that CBPHC can improve child health? • What are the conditions needed for community-based interventions to be effective? • What lessons have been learned? • What additional research needed is need? • What are the policy implications?

4. Study Outcomes • Report to Expert Panel • Journal supplement • Consensus statement of Expert Review Panel • Summary publication of key findings in high-profile journal • Book

5. Identification of Documents for the Review • One or more interventions with outcome assessment • Main outcome measures: -Change in mortality -Change in nutritional status -Change in coverage of a key child survival intervention

6. Sources and Selection Criteria Computerized database searches – Pubmed Broadcasts to global health listserves Knowledgeable persons Reviews of studies also included where appropriate Documents from grey literature included

7. Document Review Process • PUBMED search produced 3,224 documents (“community health” AND “infant/child morbidity or mortality” AND “developing countries”) • Each document assessed for inclusion by two independent reviewers • Each document which qualified for inclusion was reviewed by 2 independent reviewers • Standardized data extraction forms used for single studies • Each pair of reviews consolidated by a third senior reviewer into a single data sheet created as an EPI INFO questionnaire for further analysis • 380 studies and 50 review articles

8. Study Personnel • Directors: Henry Perry and Paul Freeman • Coordinators: Sundeep Gupta and Bahie Rassekh • 70 reviewers (mostly volunteer, including many Hopkins students)

9. Members of the Expert Review Panel • Dr. Carl Taylor, Chairperson, Johns Hopkins University, Baltimore, MD • Dr. Raj Arole, Comprehensive Rural Health Project, Jamkhed, India • Dr. Rajiv Bahl, World Health Organization, Geneva • Dr. Abhay Bang, Society for Education, Action and Education (SEARCH), Gadchiroli, India • Dr. Robert Black, Johns Hopkins University, Baltimore, MD, USA • Dr. Anthony Costello, University College of London, London, UK

10. Members of the Expert Review Panel (cont.) • Betty Kirkwood, London School of Hygiene and Tropical Medicine, London, UK • Rudolph Knippenberg, UNICEF, New York, NY • Claudio Lanata, Institute of Nutritional Research, Lima, Peru • Dr. Adetokumbo Lucas, Harvard University, Ibidan, Nigeria • Dr. Pang Ruyan, WHO, Manila, Philippines • Dr. David Sanders, University of Western Cape, Capetown, South Africa • Dr. Agnes Soucat, World Bank, Washington, DC • Dr. Mary Taylor, Gates Foundation

11. What Is CBPHC? • Broad-based definition • Any interventions(s) outside of health facilities or in coordination with health facilities with a direct or indirect effect on health

12. Main Findings: CBPHC Interventions for Improving Child Health

13. CBPHC Interventions for Improving Child Health

14. CBPHC Interventions for Improving Child Health

15. Selected Findings from the Review: Effective CBPHC Interventions • Community-based treatment of pneumonia is effective • Water and sanitation interventions are effective • Handwashing reduces rates of childhood diarrhea AND pneumonia • Women’s empowerment, cash transfers, micro-credit, overall social/political environment each contribute to child health Some Comments on the Evidence for Specific Interventions: Family and community practices that promote child survival, growth and development. A REVIEWOF THE EVIDENCE http://whqlibdoc.who.int/publications/2004/9241591501.pdf

16. Meta-Analysis of Studies to Improve the Quality of Drinking Water (33 studies) • Types: household-based (chlorination, filtration, flocculation/ disinfection, solar disinfection) and source-based chlorination • Overall, 39% reduced risk of childhood diarrhea • Addition of other interventions (e.g., hygiene instruction, improved water vessel storage, improved sanitation, or improved water supply) does not increase effectiveness (Clasen et al., British Medical Journal, 2007)

17. Review of Potential Effectiveness of Nutrition Interventions (thousands of studies) -- In the 36 countries with the 90% of children with stunting -- All interventions are community-based Bhutta et al., Lancet, 2008

18. Evidence for Integrated Approaches:Analysis of Integrated Projects Included in the Review • Review of studies with at least 3 child survival interventions and at least 4 years of implementation • 40 studies/projects identified

19. Characteristics of 40 Integrated Projects

20. Community Processes Used in Intervention Implementation

21. Common Methods of Outreach • Censuses/mapping/family registration common • Routine home visitation common • Drama/dance/ songs/puppet shows used to attract the community for health education events

22. Examples of Types of Community Involvement/Participation At community leadership level • Village health committees • Associations of village health committees • Village development committees • Health action committees • Community leadership committees • Meetings with chiefs/mayors/ elders/imams • Imams as community mobilizers • Community meetings/assemblies • Community pharmacies • Self-sufficient maternity homes At household level • Health days (for community clean up) • Model mothers • Competitions among mothers for healthiest babies • Breastfeeding support groups • Husbands and mothers-in-law as targets for messages • Pregnant women’s groups • Mothers’ clubs • Child clubs

23. Outcomes of 40 Integrated Projects

24. Review of Studies of the Effectiveness of Packages of Community-based Neonatal Health Interventions (41 studies) • Packages of interventions which had more than 1 plausible biological effect • Few studies of any “complete” packages (antenatal, intrapartum and postpartum) which were recommended in the Lancet neonatal series • Interventions appeared t o be bundled on basis of convenience or funding requirements • No studies of true effectiveness of packages (in routine conditions) at scale Haws et al., Health Policy and Planning 2007

25. Matlab (Bangladesh) Infant and 1-4-Year Mortality Rates in Intervention and Comparison Areas

26. Jamkhed CRHP Infant Mortality Rates Compared to Estimated Rates for Rural Maharahstra Note: Rates for rural Maharashtra are the infant mortality rates among mothers with less than 5 years of education for the entire state inflated by 10% since rural rates in general are 10% greater than rates for the overall population.

27. Books Freedom from Want The Remarkable Success Story of BRAC, the Global Grassroots Organization That’s Winning the Fight Against Poverty Ian Smillie Learning to Reach Health for All: Thirty Years of Instructive Experience at BRAC Jon E Rohde

28. Hospital Albert Schweitzer (Haiti), Imesi Ile/Wesley Guild (Nigeria), Matlab (Bangladesh), Jamkhed (India), BRAC (Bangladesh), SEARCH (India), and Navrongo (Ghana)