Koki Agarwal, Director Rebecca Levine, Program Officer Maternal and Child Health Integrated Program

1. Lives Saved Tool: Using LiST for Maternal, Newborn, and Child Health Advocacy Koki Agarwal, DirectorRebecca Levine, Program OfficerMaternal and Child Health Integrated Program

2. The Maternal and Child Health Integrated Program (MCHIP) • USAID Bureau for Global Health’s flagship maternal, newborn and child health program • Working in well over 30 countries worldwide • MCHIP supports programming and opportunities for integration in: • Maternal, Newborn and Child Health • Immunization, Family Planning, Malaria, HIV/AIDS • Wat/San, Urban Health, Health Systems Strengthening

3. Session Outline • Advocacy Tools for Global Health • Overview of Lives Saved Tool (LiST) • Benefits & Limitations of LiST • How LiST has been used for Global Health Advocacy • How MCHIP has used LiST for Advocacy • Recommendations based on Experience

4. GLOBAL HEALTH ADVOCACY TOOLS

5. What Tools Exist for Global Health Advocacy? • REDUCE An advocacy model for reducing maternal mortality, morbidity, and disability. Developed by the SARA Project. • Safe Motherhood ModelA computer program to examine the impact of maternal health services on the maternal mortality ratio • ALIVE An advocacy model for saving newborn lives • Marginal Budgeting for Bottlenecking (MBB) Aims at estimating the potential impact, resources needs, costs and budgeting implications of country strategies to remove implementation constraints of the health system.

6. WHAT IS THE LIVES SAVED TOOL?

7. The Lives Saved Tool - LiST 7 Goal of LiST To promote evidence-based decision making and aid in the planning for expansion of maternal, neonatal and child health interventions Objectives To estimate potential lives saved when introducing or scaling up key MNCH interventions

8. The Lives Saved Tool - LiST The Lives Saved Tool • A computer-based software that models multi-causes of mortality Predicts changes in • Under-five and neonatal mortality rates and deaths • Maternal mortality ratios and deaths • Causes of death Based on changes in health intervention coverage levels Using • Country specific fertility and HIV information and trends • Country specific health status information • Effect sizes of interventions (based on RCT studies) • Baseline intervention coverage values (60+)

9. Which Interventions Are Included? Proximal factors • Not distal (being equal) Work through health programs • Not included: income, education and crowding, etc. • Water and sanitation are the exceptions Feasible in a low income country • 68 priority countries with highest MNCH mortality Cause-specific evidence of effect • Research studies or systematic reviews • Delphi method if research is impossible (i.e. CEmOC) • Updated as new evidence is published • Several published International Journal of Epidemiology (Apr 2010)

10. Intervention Types • Maternal, neonatal, child ex. AMTSL, Neonatal Resuscitation, Rotavirus vaccine • Periconceptional, antenatal, birth, immediate postnatal, child ex. Folic acid supplementation, IPTp malaria, delivery care, routine postnatal care, antimalarials • Preventive, curativeex. Vitamin A, Pneumonia case management • Immediate, time-laggedex. ORS, breastfeeding

12. What’s NOT Calculated in LiST? Education Motivation Gender issues Economic status Emergencies (i.e. famine, flooding) Delivery mechanism Quality of care

13. What Information Can LiST Provide? Number of deaths • Total, by cause, by age group Mortality rates/ratios (NMR, U5MR, MMR) Deaths averted (Lives Saved) • Total, by cause, by intervention, by age group Intermediate outcomes • Stunting, breastfeeding Displays (over a chosen period of time) • Tables, graphs, pie charts • Single country, multiple scenarios within one country • Multiple countries, single or multiple scenarios

14. Some Limitations of LiST Data availability • If no baseline, can’t evaluate impact accurately Data quality User Friendliness Sensible scale up targets • Feasible, acceptable, funds available Interventions included in software Costing/budgeting considerations** Links to existing costing tools including MBB and the WHO supported costing tool for child survival are being developed

15. Using LiST for Advocacy

16. The Lancet South Africa series – August 2009 The Lancet, Volume 374, Issue 9692, Pages 835 - 846, 5 September 2009 NEONATAL • Obstetric care packages • Resuscitation • Kangaroo mother care • Facility case mx of neonatal illness 12,200 lives saved in 2015 PMTCT • Dual therapy • Appropriate feeding 37,000 lives saved in 2015 "We cannot allow a single…neonate to die because of our negligence...it will be criminal for us to allow any of these things to happen. “ Minister of Health Dr Aaron Motsoaledi, South Africa Source: Chopra M, Lawn et al Lancet 2009

17. National situation analyses for newborn health in Africa National as well as sub-national analysis e.g. 36 states in Nigeria, 3 regions in Mali, South Sudan

18. “Science in Action” African Science Academies Development Initiativehttp://www.nationalacademies.org/asadi/2009_Conference/PDFs/ScienceInActionFullReport.pdf Country specific lives saved and cost for: • Births in facilities – achievable missed opportunities to save lives • Outreach or community interventions – achievable increases (20%) • For Ethiopia, Kenya, Nigeria, Uganda, Tanzania, Senegal, Cameroon, South Africa

19. MCHIP & LiST

20. How LiST is being used at MCHIP 20 Strategic Planning for country workplans • Which interventions are necessary to reduce mortality? (maternal, neonatal, under-5) • Based on feasible targets, what potential reduction in mortality will our program have? Can counteract current emphasis on one-size-fits-all intervention packages, by suggesting which specific interventions are more likely to have an impact in different contexts

21. Helping to Reach MDG 4 in Zimbabwe: Under 5 Mortality Rate Zimbabwe Current Trend Zimbabwe MCHIP Package Zimbabwe 90% Maternal Health Coverage Implementation begins in 2010 Zimbabwe MDG 4 Target

22. Helping to Reach MDG 5 in Zimbabwe: Maternal Mortality Ratio Zimbabwe Current Trend Zimbabwe MCHIP Package Zimbabwe 90% Maternal Health Coverage MDG Goal for Maternal Mortality Zimbabwe MDG 5 Target

23. Decreased Child Deaths in Zimbabwe

24. How LiST is being used at MCHIP con’t 24 Advocacy and Planning

25. MCHIP Lessons Learned & Recommendations

26. What LiST Is, What LiST Isn’t Is Isn’t • Multi-cause mortality model • Mathematic model • Models coverage impacts • Potential impact assessment • National or sub-national planning tool • Discussion points • Evidence-based • Effective advocacy tool • Truth • Probabilistic model • Natural history model • Detailed costing or planning tool • Bottlenecks, budgeting • Exhaustive 26

27. Food for Thought Maternal Health Intervention Assumptions: Because of the much smaller numbers of maternal deaths & the continuing work to determine the impact that some interventions have on maternal survival, LiST may not be the best tool to weigh the relative value of different investments in maternal survival MH interventions included in LiST are packages that are only effective in reducing mortality if all services are provided at quality

28. Food for Thought It is often just as important to show the impact of scaling back interventions that already have high coverage levels (ie. Lives LOST due to roll-back in coverage) Particularly important for mature interventions (i.e. Immunization, Vit A coverage) We do not want projections to inadvertently make the case for decreasing funding/coverage for these interventions

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