Bridging the gap: taking evidence-based interventions to millions in developing countries

1. Bridging the gap: taking evidence-based interventions to millions in developing countries Jorge Hermida, M.D. University Research Co., LLC International Forum, Paris April 2014

2. No conflicts of interest declaration • The funds that cover my attendance to this Conference come from the USAID Applying Science to Strengthen and Improve Systems, ASSIST Project.

3. Maternal mortality annual Rates of Reduction (1990-2010) within MCH priority countries. (WHO 2012a) A maternal death in low and middle-income countries (LMIC) remains 100 times more likely than in high-income countries (Lozano R et al, 2011)

4. Accelerating progress on child survival – what can the world achieve if countries increase their annual rate of reduction? Under-5 deaths millions 13 Under-five deaths 1990-2070 (actual and projected) 12 9.6 mm deaths in 2000 11 10 7.6 mm deaths in 2010 9 8 • Current trajectory: ARR 2.5% • MDG 4 achieved in 2035 • 4 million deaths annually in 2035 7 • ARR 5.2% • 2 million deaths annually by 2035 • Every country reaches 20/1000 by 2035 • Many countries below 15/1000 by then • ARR 12.6% • Achieve MDG 4 • Reach 2 million child deaths annually in 2020 • Achieve average of U5MR 15/1000 by 2020 6 5 4 3 Achieve MDG 4 2 1 0 Source: UNICEF State of the World’s Children 2012; The UN Inter-agency Group for Child Mortality Estimation, Levels and Trends in Child Mortality: Report 2011, 2011; Team analysis from 2035 onward based on straight-line ARR reduction from UNICEF numbers 1990-2035

5. USAID Applying Science to Strengthen and Improve Systems

6. High Impact Practices—proven interventions can address leading causes of maternal death • Requejo J, Bryce J, Victora C. Building a Future for Women and Children: The 2012 Report. Washington D.C.: World Health Organization & UNICEF, 2012.

7. Median coverage for effective maternal, newborn, and child interventions in 68 Countdown countries ZulfiqarA.Bhutta, The Lancet,Volume 375, Issue 9730,

8. Coverage with what? The devil is in the details • “Skilled” attendance at birth in Ecuador: 95% • Actual implementation of evidence-based practices at start of improvement program ~1995: • Use of the partograph: 45% • Oxitocin for prevention of PPH: 15% • Postpartum care as per standards: 8% • Dexamethasone for fetal lung maturation in preterm birth: 10% • Premature rupture of membranes as per standards: 5% USAID Applying Science to Strengthen and Improve Systems

9. Analysis of the Results from 27 Improvement Collaboratives in 12 Countries. The Health Care Improvement Project, 2010 77% 52% 33% 10% Franco LM, L Marquez, K Ethier, Z Balsara, and W Isenhower. 2009. USAID Health Care Improvement Project. Bethesda, MD: University Research Co., LLC (URC).

10. Increasing inputs may be necessary but not sufficient to achieve implementation results at scale System’s Policy Environment Processes Inputs Implementation Results • More personnel • More training • More equipment and supplies • More regulation (guidelines, standards, accreditation) USAID Applying Science to Strengthen and Improve Systems

11. Increasing inputs may be necessary but not sufficient to achieve implementation results at scale Inputs Implementation Results Processes • More personnel • More training • More equipment and supplies • More meetings USAID Applying Science to Strengthen and Improve Systems

12. Modern quality improvement: Making changes in systems and processes to improve outcomes Engages teams of providers and other staff Focuses on client needs Analyzes systems and processes Empowers teams to make changes Guided by data to measure results Langley et al, 1999, The Improvement Guide USAID Applying Science to Strengthen and Improve Systems

13. ContinuousQualityImprovementteams at work: • What are we trying to accomplish ? • How will we know a change resulted in improvement? • What specific, concrete changes can we test ? Plan Do IMPLEMENT AND TEST THE CHANGES Act Study USAID Applying Science to Strengthen and Improve Systems

14. Improving the use of the partograph in Uganda, 2013 USAID Applying Science to Strengthen and Improve Systems

15. Improving Esential Newborn Care, Uganda 2013 USAID Applying Science to Strengthen and Improve Systems

16. Mali: AMTSL & post-partum hemorrhage management AMTSL coverage and post-partum hemorrhage rates in 41 target facilities, Kayes & Diema Districts, Mali, Oct. 2009 – Dec. 2011 Average # monthly births: 1,024 USAID Applying Science to Strengthen and Improve Systems

17. THE PRODUCT OF THE “DEMONSTRATION PHASE” IS KNOWLEDGE ON HOW TO IMPROVE SPECIFIC PROCESSES

18. Scaling up improved processes in Developing Countries Product: Effectivechanges implemented at largerscale and spread tosystem Product: Knowledgeaboutwhatworks toovercomeobstaclestobestpractices Product: Collaborative readyforimplementation USAID Applying Science to Strengthen and Improve Systems

19. 97 hospitals 23 centers 20 provinces 82 hospitals 10 centers 20 provinces 75 hospitals 21 centers 20 provinces 59 hospitals 22 centers 18 provinces Direct technical assistance from QAP ends 45 hospitals 08 centers 11 provinces 43 hospitals 09 centers 11 provinces “Intensive” AMTSL Spread Collaborative 21 hospitals 07 centers 05 provinces USAID Applying Science to Strengthen and Improve Systems

20. Ecuador - Comparison of Demonstration vs. Scale up Sites for Compliance with AMTSL USAID Applying Science to Strengthen and Improve Systems

21. Scaling up results in Afghanistan USAID Applying Science to Strengthen and Improve Systems

22. USAID Applying Science to Strengthen and Improve Systems

23. Moving on to the next level: standardized “best improvement approaches” to common deficiencies • For specific key processes of care (MNCH, HIV/AIDS, NCD, TB, etc. in LMIC countries: • Choosing priority common improvement aims • Developing common best measurements (indicators, data sources, etc.) for improved processes of care • Identifying a common set of frequent process deficiencies • Selecting specific changes (or bundles of changes) that have worked well in several settings • Testing direct large-scale applications at calculated costs and times, and measuring impact • Thank you!