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

Community sites informing programmes and policies

Anthony CostelloUCL Centre for International

Health and Development

India IMR trends

Technical Behavioural

EnvironmentalEnvironmental

Supply

Demand

Interventions e.g drugs, supplements, vaccinesKnowledge and skillsQOC/MIS/Facilities

Referral

MotivationLeadership

Work cultureCommunication

Knowledge, beliefs, and culture

Decision-makingDelays in seeking care Social capital/networks

Economic access/equity

VectorsWater and sanitation

PollutionPesticides

Slum transferParks and play

VectorsWater and sanitation

PollutionPesticides

Slum transferParks and play

HH or communityGovernance

TechnicalQuality of Care

BehaviouralAppreciative inquiry

EnvironmentalEnvironmental

Supply

Demand

HH or community

Urban 80% hospital deliveries

Governance

TechnicalQuality of Care

BehaviouralAppreciative inquiry

EnvironmentalVectorsWater

EnvironmentalVectorsWater

Supply

Demand

HH or communityAgents of changeWomens groups

Traditional health systemsEquity

Rural 15% hospital deliveries

Governance

Efficacy and effectivenessAntibiotics 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%

Principles of essential newborn careAir/breathing/resuscitationWarmthEarly breastfeedingHygieneKeep with motherTreat illness and infection promptly

0

100

200

300

400

500

600

700

1900 1905 1910 1915 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980

Maternal deathsInfant deaths

MMR reduction, England and Wales

Principles of essential obstetric careAntenatal careHygiene Birth preparedness to avoid delaysSkilled attendantAccess to emergency obstetric carePostnatal care

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

On the road

Maternity access

How do we know whether our policies and programmes are

working?

Wisdom of elders?NO. WE NEED EVIDENCE, DATABecause it has worked somewhere else?BUT POPULATION MAY BE DIFFERENTBefore and after study?YES, OK, BUT CONFOUNDERSControl area vs intervention area?BETTERRandomised controlled trial?BEST, BUT NOT ALWAYS FEASIBLE

Technical Behavioural

EnvironmentalEnvironmental

Supply

Demand

Interventions e.g drugs, supplements, vaccinesKnowledge and skillsQOC/MIS/Facilities

Referral

MotivationLeadership

Work cultureCommunication

Knowledge, beliefs, and culture

Decision-makingDelays in seeking care Social capital/networks

Economic access/equity

VectorsWater and sanitation

PollutionPesticides

Slum transferParks and play

VectorsWater and sanitation

PollutionPesticides

Slum transferParks and play

HH or communityGovernance

BANG

TBA

VHW

60% fall in NMR

Technical Behavioural

EnvironmentalEnvironmental

Supply

Demand

Interventions e.g drugs, supplements, vaccinesKnowledge and skillsQOC/MIS/Facilities

Referral

MotivationLeadership

Work cultureCommunication

Knowledge, beliefs, and culture

Decision-makingDelays in seeking care Social capital/networks

Economic access/equity

VectorsWater and sanitation

PollutionPesticides

Slum transferParks and play

VectorsWater and sanitation

PollutionPesticides

Slum transferParks and play

HH or communityGovernance

MicronutrientsIn pregnancy

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

Iron 60 mgFolic acid 400 mcg

Control

Vitamin A 800 mcgVitamin B1 1.4 mgVitamin B2 1.4 mgVitamin B6 1.9 mgVitamin B12 2.6 mcgVitamin C 70 mgVitamin D 5 mcgVitamin E 10 mgNiacin 18 mgFolic acid 400 mcgIron 30 mgZinc 15 mgCopper 2 mgSelenium 65 mcgIodine 150 mcg

Intervention

77g increase in birth weight

Iron & folate

Multiple micronutrients

Stillbirth rate 34 42

Early NMR 20 32

Late NMR 10 13 RR (95% CI)

PMR 53.3 72.5 1.36 (1.02, 1.81) NMR 29.5 44.8 1.52 (1.03, 2.25)

Combined mortalityJanakpur and Sarlahi trials, Nepal

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

Technical Behavioural

EnvironmentalEnvironmental

Supply

Demand

Interventions e.g drugs, supplements, vaccinesKnowledge and skillsQOC/MIS/Facilities

Referral

MotivationLeadership

Work cultureCommunication

Knowledge, beliefs, and culture

Decision-makingDelays in seeking care Social capital/networks

Economic access/equity

VectorsWater and sanitation

PollutionPesticides

Slum transferParks and play

VectorsWater and sanitation

PollutionPesticides

Slum transferParks and play

HH or communityGovernance

Appreciative Inquiry

Appreciating what staff (and mothers) do in difficult circumstances

Technical Behavioural

EnvironmentalEnvironmental

Supply

Demand

Interventions e.g drugs, supplements, vaccinesKnowledge and skillsQOC/MIS/Facilities

Referral

MotivationLeadership

Work cultureCommunication

Knowledge, beliefs, and culture

Decision-makingDelays in seeking care Social capital/networks

Economic access/equity

VectorsWater and sanitation

PollutionPesticides

Slum transferParks and play

VectorsWater and sanitation

PollutionPesticides

Slum transferParks and play

HH or communityGovernance

Women’s Agency

Dr T Sundararaman from State Health Resource Centre, Chhattisgarh

Activities of mitanins

Agents of change for demand side intervention

MIRA Makwanpur Study

Cluster randomised controlled trial

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

Supply Demand

1 local woman facilitator per clusterNot a health worker7000 population, 60 sq km9 monthly women’s groupsOnly 8% coverage of target married women

The intervention

Problem Identification

Planning together

Implementation

Participatory evaluation

Year 2

Control Intervention Adjusted OR

95% CI

Stillbirth rateper 1000 births

23.3 24.6 1.06 0.76 - 1.47

NMRper 1000 live births

36.9 26.2 0.70 0.53 - 0.94

MMRper 100,000 live births

341 69 0.22 0.05 - 0.90

Mortality rate comparison

Reductions in maternal and newborn mortality larger than expected

$110 per group per year plus $203 for supervision

$0.75 per capitaCost per life year saved: $211 but for

expansion could fall to $138. Borghi et al, Lancet 2005

Cost

One woman facilitator

8% MWRA in groups

37% newly pregnant women in groups

?% non-group pregnant women

Amplification

Scepticism about findings

Will it work elsewhere?

Need several studies to change policy

Bangladesh

India, Jharkand

India, Mumbai

Nepal MIRA Dhanusha trial

Malawi

Lancet Sept 30 2006, Rosato, Mwansambo et al.

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