1 ou mar. 2009 child survival – how many deaths can we prevent and at what cost?

1OU Mar. 2009

Childsurvival – how many

deaths can we prevent and

at what cost?

2OU Mar. 2009

• An evidence based approach to reducing under-5 deaths.

• Estimation of costs

• Actual experiences

Child mortality and aspects to be covered

Worldwide around 10 million children under 5 years of age are dying each year

3OU Mar. 2009

Mortality by cause

Interventions

Impact on mortality

Model

A model for linking interventions to Impact on under-5 mortality

Resources

4OU Mar. 2009

Mortality by cause

Impact on mortality

ModelResources

Interventions


5OU Mar. 2009

0%

5%

10%

15%

20%

25%

30%

Diarrh

ea

Pneum

onia

Mea

sles

Mala

ria

HIV/A

IDS

Neona

tal

Other

Cause

Pe

rcen

t

Under-five deaths by cause, 2000Sub-Saharan Africa

24 countries in which over 90% of under-5 deaths occur

Neonatal division

Asphyxia - 29%

Sepsis - 25%

Tetanus - 7%

Prematurity - 24%

(Other is 15%)

6OU Mar. 2009

Mortality by cause

Impact on mortality

ModelResources

Interventions


7OU Mar. 2009

Intervention selection

Central criterion for selection of any intervention is feasibility for delivery at high levels of population coverage in low-income countries.

Each potential intervention assigned to one of three levels based on the strength of evidence for its effect on child mortality.

1 – sufficient evidence of effect

2 – limited evidence of effect

3 – Inadequate evidence of effect

8OU Mar. 2009

Interventions by cause - diarrhoea

Exposure to diarrhoea

Diarrhoea

SurviveDie

Breastfeeding

Complementary feeding

Treatment

Zinc

Future: rotavirus vaccine

Vitamin AAntibiotics for dysentry

Oral rehydration therapy

Zinc

Water/San/Hygiene

Prevention

9OU Mar. 2009

Interventions, neonatal - prematurity

Pregnant

Premature

SurviveDie

Insecticide-treated materials*Intermittent preventive therapy

Newborn temperature management

Prevention Treatment

Antinatal steroids

Antibiotics for premature rupture of membrane

* Indoor residual spraying may be used as an alternative

10OU Mar. 2009

Mortality by cause

Impact on mortality

ModelResources

Interventions


11OU Mar. 2009

For each of the 24 countries in sub-Saharan Africa, the number of under-5 deaths that could be prevented was calculated with coverage levels around the year 2000 increased to 99% except for exclusive breastfeeding, where 90% was used. The calculations divided into three types:

Exclusive and continuing breastfeeding, as this involved three levels: exclusive, partial and no breastfeeding

Complementary feeding, which utilized the underweight distribution of under-5s within a country

All other interventions.

Lancet model – calculation types

12OU Mar. 2009

For the majority of calculations the proportionate reduction of deaths when intervention coverage is increased from the current value (pc) to target (pt) is

= AfEf(pt - pc)/(1 – pcEf)

where Ef is the efficacy of the interventionand Af is the fraction of deaths affected by the intervention.

Lancet model – calculation of deaths averted

13OU Mar. 2009

Malaria

Evid. level Intervention

Current coverage

Target coverage Efficacy

Affected fraction

1 P1Complementary feeding by country

shift of N z-score towards

mean by country

1 P2 ITM by country 0.99 0.75malaria

countries only

2 P3 Vitamin A by country 0.99 0.44

by country (and only for 6

months plus)

2 P4 Zinc 0 0.99 0.36 by country

1 T5 Anti-malarials by country 0.99 0.67malaria

countries only

Lancet model – parameters

14OU Mar. 2009

Mortality by cause

Impact on mortality

ModelResources

Interventions


15OU Mar. 2009

Results are calculated on the basis of the situation in the year 2000.

Under-5 deaths preventable through the universal application of the level 1 and 2 interventions were of three types – deaths preventable by:

individual intervention

specific cause

group of interventions

Lancet model – results by intervention type

16OU Mar. 2009

Percent of total deaths averted by single interventions - prevention

0% 2% 4% 6% 8% 10% 12% 14% 16% 18%

Insecticide-treated materials

Breastfeeding


Zinc

Hib vaccine

Clean delivery

Nivirapine & replacement feeding

Water/San/Hygiene

Vitamin A

Antenatal steroids

Measles vaccine


Tetanus toxoid

Antibiotics - PRM

Antimalarial IPT in pregnancy

Inte

rven

tion

PercentSub-Saharan Africa

17OU Mar. 2009

Percent of total deaths averted by single interventions - treatment

0% 2% 4% 6% 8% 10% 12% 14% 16%

Oral rehydrationtherapy

Antimalarials

Antibiotics -pneumonia

Antibiotics - sepsis

Zinc

Antibiotics -dysentery

Newbornresuscitation

Vitamin A

Inte

rven

tion

PercentSub-Saharan Africa

18OU Mar. 2009

Preventable under-five deaths by causeSub-Saharan Africa

Disease or condition

Under-five deaths (in '000s) 2000

Percent of total under-five deaths

Number (in '000s) Percent

Diarrhoea 815 20% 720 88%Pneumonia 878 22% 583 66%Measles 77 2% 77 100%Malaria 889 22% 806 91%HIV/AIDS 288 7% 139 48%Neonatal 1020 25% 573 56%

Asphyxia 296 7% 115 39%Prematurity 245 6% 155 63%Severe infections 255 6% 244 96%Tetanus 71 2% 59 83%Other 153 4% 0 0%

Other 92 2% 0 0%TOTAL 4070 100% 2898 71%

Preventable under-five deaths

19OU Mar. 2009

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Health facilitycentric

Health facilityoutreach

Home care

Location type

Per

cent

Interventions by locationHealth facility centric includes: antenatal steroids, temperature management, antibiotics-PRM, antibiotics-pneumonia, antibiotics-sepsis, rescusitation, antibiotics-dysentry, zinc-T and vitA-THealth facility outreach includes: zinc, hib vaccine, vitA, tetanus toxoid, nivirapine, clean delivery, measles, IPT and antimalarialsHome care includes: breastfeeding, complementary feeding, ITM and ORT

Sub-Saharan Africa

Percent of deaths averted by location of interventions

20OU Mar. 2009

Mortality by cause

Interventions

Impact on mortality

ModelResources


21OU Mar. 2009

Costing the reduction of under-5 deaths

Costs are difficult to assess:

• Commission on Macro-economics and Health estimated US$7.5 billion, but not specifically for child mortality reduction

• Single disease estimates, such as HIV/AIDS, malaria and measles have been made, but little use for reduction of child mortality

However, with publication of cause-of-death estimates and Lancet model on child deaths that could be averted through use of a package of effective interventions, more can be done on costing the achievement of the MDG on child survival

22OU Mar. 2009

Under-five deaths averted and related costs(Application of single interventions only)

Intervention

Deaths averted

(in '000s)

Percent (of total deaths)

For 2000 coverage

levels

Additional for universal coverage

Breastfeeding 1301 13% 102 414Insecticide-treated materials 691 7% 1 77Complementary feeding 587 6% 46 158Zinc 459 5% 0 301Clean delivery 411 4% 502 653Hib vaccine 403 4% 66 1051Water/San/Hygiene 326 3% 1889 753Antenatal steroids 264 3% 61 420Newborn temperature management 227 2% 19 79Vitamin A 225 2% 129 271Tetanus toxoid 161 2% 71 161Nivirapine & replacement feeding 150 2% 1 82Antibiotics - PRM 133 1% 44 52Measles vaccine 103 1% 39 30Antimalarial IPT in pregnancy 22 0% 0 26Total 2970 4528(Global - 42 countries with 90% of all under-5 deaths)

Estimated annual running costs (millions US $)Prevention

Source: Bryce et al, Can the world afford to save the lives of 6 million children each year? Lancet June 2005

23OU Mar. 2009


Intervention

Deaths averted

(in '000s)


For 2000 coverage

levels


Additional cost as %

of sum

Breastfeeding 1301 13% 102 414 9%Insecticide-treated materials 691 7% 1 77 2%Complementary feeding 587 6% 46 158 3%Zinc 459 5% 0 301 7%Clean delivery 411 4% 502 653 14%Hib vaccine 403 4% 66 1051 23%Water/San/Hygiene 326 3% 1889 753 17%Antenatal steroids 264 3% 61 420 9%Newborn temperature management 227 2% 19 79 2%Vitamin A 225 2% 129 271 6%Tetanus toxoid 161 2% 71 161 4%Nivirapine & replacement feeding 150 2% 1 82 2%Antibiotics - PRM 133 1% 44 52 1%Measles vaccine 103 1% 39 30 1%Antimalarial IPT in pregnancy 22 0% 0 26 1%Total 2970 4528(Global - 42 countries with 90% of all under-5 deaths)

Estimated annual running costs (millions US $)Prevention


24OU Mar. 2009


Intervention

Deaths averted

(in '000s)


For 2000 coverage

levels


Additional cost as %

of sum

Oral rehydration therapy 1477 15% 29 124 12%Antibiotics - sepsis 583 6% 101 17 2%Antibiotics - pneumonia 577 6% 290 332 32%Antimalarials 467 5% 200 46 4%Zinc 394 4% 0 150 14%Newborn resuscitation 359 4% 19 35 3%Antibiotics - dysentery 310 3% 284 333 32%Vitamin A 8 0% 52 0 0%Total 975 1037(Global - 42 countries with 90% of all under-5 deaths)

TreatmentEstimated annual running

costs (millions US $)


25OU Mar. 2009

Child mortality reduction: effects of varying assumptions on additional running costs

Variable assessed Low High Low High

Country specific cost of community delivery agent relative to cost of a midwife (originally 75%)

50% 100% 4311 5955

Drug costs -25% +25% 4598 5669

Existing intervention coverage level in year 2000

+25% -25% 4210 6374

All three variables 3111 8083

Variable valueAdditional annual running

cost (US $ millions)

Individual country costs and situations differ widely


26OU Mar. 2009

Costing assumptions

Average cost per death averted about $890, with neonatal death averted at around $780. But 2005 Lancet neonatal series estimated death averted cost of $2100 (over half of this due to provision of emergency obstetric care).Estimates did not include capital, hiring, training and other infrastructure development costs.

Consumer costs were not included.

Vaccines and drug cost estimates do not account for expected cost reduction as demand increases

However, resources linked to appropriate intervention packages are critical if money is to be effectively used to reduce child mortality

27OU Mar. 2009

Experiences in Africa

28OU Mar. 2009

18 countries in Eastern and Southern Africa Region implement the household and community component of the IMCI strategy

The common element: promotion of the key family care practices

IMCI early implementation phase

IMCI expansion phase

IMCI household and community component in at least 3 districts (18 countries)

IMCI in the Eastern and

Southern Africa Region

29OU Mar. 2009

The Review2004-2005

• ESAR country experiences with implementing IMCI household and community-based activities (focusing on four countries--Malawi, South Africa, Tanzania, Uganda)

• Scientific evidence for the importance of family care practices for a child’s survival, health, and development

• Survey evidence on changes in family care practices in four focus countries

30OU Mar. 2009

Context

31OU Mar. 2009

0% 2% 4% 6% 8% 10% 12%

Insecticide-treated materials

Breastfeeding

Zinc


Nivirapine & replacement feeding

Hib vaccine

Clean delivery

Vitamin A

Water/San/Hygiene

Antenatal steroids


Measles vaccine

Tetanus toxoid

Antibiotics - PRM

Antimalarial IPT in pregnancy

Inte

rve

ntio

n

Percent

Percent of total deaths preventable by single prevention interventions in the Eastern and Southern Africa

Region*

* Based on 13 countries contributing 95% of under-5 deaths in the Eastern and Southern Africa Region

Interventions that have the most direct impact on the child—and could make the most difference…

Prevention

By intervention

32OU Mar. 2009

0% 2% 4% 6% 8% 10% 12% 14%

Oral rehydrationtherapy

Antimalarials

Antibiotics -pneumonia

Zinc

Antibiotics -sepsis

Antibiotics -dysentery

Newbornresuscitation

Vitamin A

Inte

rven

tion

Percent

Percent of total deaths preventable by single treatment interventions in the Eastern and Southern Africa Region*

* Based on 13 countries contributing 95% of under-5 deaths in the Eastern and Southern Africa Region

Treatment

33OU Mar. 2009

By location of interventionHealth facility outreach includes: zinc, hib vaccine, vitA, tetanus toxoid, nivirapine, clean delivery, measles, IPT and antimalarials

Home care includes: breastfeeding, complementary feeding, ITM, WASH and ORTPartial coverage60% malaria interventions (Abuja target)

70% excl. breastfeeding and all others 0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Health facilitycentric

Health facilityoutreach

Home care

Per

cent

Universal Partial

Percent of total deaths preventable by groups of location associated

interventions

34OU Mar. 2009

Findings

35OU Mar. 2009

Children exclusively breastfed up to age 6 months in five ESAR

sites (baseline and follow-up)

0

10

20

30

40

50

60

70

80

90

100

Pe

rce

nt

Baseline

Follow-up

Breastfeeding

Improving breastfeeding practices could prevent the deaths of 233,000 children in ESAR.

36OU Mar. 2009

Practice

Deaths preventable by full coverage of

a single intervention

(% total)

Example: Malawi

Improved Mixed

Sample changes from 2000 to 2004 in implementing sites

in five districts

PREVENTION Breastfeeding

13 % EBF improved from 25% to 55%

Insecticide-treated bednets and other materials

12 % Under-5s sleeping under ITN increased from 38% to 65%


7 % Feeding practices improved, but quality of food decreased

Vitamin A 3 % Vitamin A supplementation increased from 49% to 65%

Water, sanitation, hygiene

3 % Facilities (e.g. water points) increased, Hygiene practices (e.g. handwashing) decreased

TREATMENT Oral rehydration therapy

14 % Children with diarrhoea offered more fluids improved from 39% to 76%, same or more food improved from 8% to 47%

Antimalarials 8 % Children with fever treated with SP at home increased from 18% to 22%

Interventions can improve multiple practices

37OU Mar. 2009

Three intervention packages

Immunization “plus” (EPI + ITNs, deworming & vitamin A)

ANC+ (Care for mother,TT, IPTp)

IMCI+ (Improved management of pneumonia, malaria

and diarrhea, and key family practices)

Accelerated child survival and development (ACSD) in West Africa

11 countries in West Africa

Support from CIDA and other partners

Aim: To reduce mortality among children less than 5 years of age

Strategy: Accelerate coverage with three packages of high-impact interventions, with a special focus on community-based delivery

38OU Mar. 2009







Routine EPI+• Strengthening routine EPI• Vitamin A supplementation

Antenatal care+ (ANC+):• Refocused ANC4• Tetanus immunization• Intermittent presumptive treatment

(IPT) against malaria• Vitamin A (post partum)

IMCI +• Family practices promotion • Exclusive breastfeeding• ORT• ITNs (pregnant and under-5s)• Community management of

malaria and ARI

Concept and aim: three packages covering three service delivery modes, plus strengthening local accountabilities through performance contracts and participatory monitoring

Started with limited package: EPI+ & ANC+ & ITNs

39OU Mar. 2009






Mali

ChadNiger

Nigeria

Cameroon

Central AfricanRepublic

Congo - Democratic Republic

Congo

SenegalCape Verde

Gabon

Equatorial Guinea

Sao Tome &Principe

GambiaGuinea Bissau

Guinea

Sierra Leone

Liberia

Burkina Faso

Ghana

TogoBenin

High Impact Package

EPI + Expansion

Accelerated Child Survival Accelerated Child Survival and and DevelopmentDevelopment

CIDA CIDA funded projectfunded project

Côte d’Ivoire

Mauritania

ACSD geographic coverage

Countries 4“high impact” Benin, Ghana, Mali, Senegal 7 “expansion”

16 “high impact”* (population ≈ 3million)

31 “expansion” (population ≈ 14 million)

Districts

*now 18 districts, because the Upper East Region of Ghana has been reorganized and now includes 8 rather than 6 districts.

40OU Mar. 2009






Evaluation questions

Coverage1. Were there changes in the ACSD “high-impact” districts?

2. Were these changes greater than in the comparison area?

Impact3. Were there changes in nutrition and mortality in the ACSD “high-

impact” districts?

4. Were these changes greater than in the comparison area?

Attribution5. Is it plausible to attribute the impact found to ACSD?

41OU Mar. 2009






Evaluation design

Intervention areas

ACSD “high impact” countries/districts (Benin, Ghana, Mali, Senegal)

Comparison areas

All other districts in the country, excluding major metropolitan areas

42OU Mar. 2009






Data sources: All existing data that met quality standards

43OU Mar. 2009






ACSD Implementation

EPI+Immunizations and vitamin A supplementation implemented first and most strongly in all four countries

ITNs started strong, but stockouts at UNICEF-Copenhagen limited provision of new nets for >1 year at crucial time

IMCI+Facility component received little support

Community component started only in mid to late 2003

Many messages, some unlikely to affect child mortalityCommunity tx of pneumonia not included at scaleACTs not available at community level in any of the three countries

Interventions to address undernutrition given low priority

ANC+

ACSD inputs focused on IPTp with SP and postnatal vitamin A

44OU Mar. 2009






Coverage for EPI+ interventionsbefore and after ACSD, in HIDs

Before ACSD

After ACSD

Key

Benin Ghana Mali

51

63

10

6

49

60

61

26

Measles

DPT

Vitamin A

ITNs

Increases in coverage across the board in Ghana and Mali; Benin achieved increases for vitamin A and ITNs.

45OU Mar. 2009






Coverage for IMCI+ interventionsbefore and after ACSD, in HIDs

Before ACSD

After ACSD

Key

No coverage gains, and some significant losses, in sick child care. Exclusive breastfeeding increased in Ghana, declined in Mali.

Benin Ghana Mali

46OU Mar. 2009






Coverage for ANC+ interventionsbefore and after ACSD, in HIDs

Before ACSD

After ACSD

Key

71

0

44

76

5

64

7

55

74

38

3+ antenatal care visits

IPTp with SP

Tetanus Toxoid

Skilled attendant at delivery

Postnatal vit A

Ghana and Mali improved care for childbearing women; delivery of TT and postnatal vit A benefited from EPI system in Mali.

Benin Ghana Mali

47OU Mar. 2009






Research question #1:

Increases in coverage in ACSD HIDs?

48OU Mar. 2009






Under-five mortality in the ACSD HIDs Research question #3:

49OU Mar. 2009






Research question #4:Under-five mortality in the ACSD HIDs and

national comparison areas

50OU Mar. 2009






Research question #5:Is it plausible to attribute the accelerated impact

found to ACSD?

Nutrition

Benin: No impact found

Ghana: Yes, for stunting, but only in period 1998 – 2003.

Mali: No impact found

Mortality

Benin: No impact found

Ghana: Unknown

Mali: No impact found

51OU Mar. 2009






Conclusions (1)

1. Intervention coverage CAN be accelerated if there is adequate funding & human resources.

2. Acceleration of mortality declines require:

a) Focus on interventions that have a large and rapid impact on major causes of child death

b) Sufficient time to fully implement approach and for coverage to translate into declines in mortality and undernutrition

c) Reasonable expectations, given level of resources

52OU Mar. 2009






Conclusions (2)

3. Policy barriers prevented key ACSD interventions directed at pneumonia and malaria from being fully implemented.

4. Breakdowns in commodities and gaps in funding vitiate progress toward impact.

5. More attention and operations research needed on incentives and supports for community-based workers

53OU Mar. 2009






Conclusions (3)

6. Careful monitoring with local capacity to use results is essential.

7. Evaluation improves programs and prospective evaluations are preferred to retrospective.

8. A new paradigm for impact evaluations is needed, that takes into account the absence of true comparison groups.

54OU Mar. 2009

Where to from here?

55OU Mar. 2009






Lives Saved Tool (LiST)

Target usersThe tool is designed for use by country- and district-level policymakers, planners and managers in low- and middle-income countries, and by technical staff in partner organizations (NGOs, multilaterals, bilaterals).

Tool highlights• Use to investigate impact on child mortality of scaling up any combination of

interventions, and estimate number of lives saved • Change population, current intervention coverage, and patterns/causes of

mortality to utilize different national or district data• Run different scenarios and compare the results• Compare across countries using different intervention package scenarios and

coverage levels• Generate outputs in form of line charts, bar charts, population pyramids, and

tables• A user-friendly interface to minimize training for use of the tool.

http://www.jhsph.edu/dept/IH/IIP/list/index.html

56OU Mar. 2009






Immediate future?

• Numerous international health initiatives – many building on the Lancet/ACSD approach

57OU Mar. 2009

Country

ACSD/ UNICEF (High-impact

only) IHPGates/ PMNCH

CI/IHSS (UNICEF)

Norwegian MDG4&5 bil.

program

Global Leaders Network (Norway)

Catalytic Initiative Aus Aid GAVI HSS**

SNL/ Save the Children large scale

evaluationsAfricaBenin X X XBurkina Faso X XBurundi X XEthiopia X X X X XGhana X X X XKenya X XLiberia X XMalawi X X X XMali X X X XMozambique X X X X X #Nepal X X XNiger XNigeria X #Senegal X XTanzania X X X X XUganda XZambia X XAsiaAfghanistan X X X #Bangladesh XCambodia X X XIndia X XIndonesia XPakistan X X X X X XViet Nam XLatin AmericaBrazil XChile X*IHP - UK, Norway, Germany, Canada, Italy, the Netherlands, France, Portugal**As of December 2007# Smaller scale or limited evaluation. Also two countries in Latin America (Bolivia and Guatemala)

Country Selection for International Health Initiatives

58OU Mar. 2009






Immediate future?

• Numerous international health initiatives – many building on the Lancet/ACSD approach

• Disease specific interventions approach vs health system strengthening

• Absorptive capacity of countries – particularly in sub-Saharan Africa

59OU Mar. 2009

1 ou mar. 2009 child survival – how many deaths can we prevent and at what cost?

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