community sites informing programmes and policies anthony costello ucl centre for international...
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Community sites informing programmes and policies
Anthony CostelloUCL Centre for International
Health and Development
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India IMR trends
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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
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TechnicalQuality of Care
BehaviouralAppreciative inquiry
EnvironmentalEnvironmental
Supply
Demand
HH or community
Urban 80% hospital deliveries
Governance
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TechnicalQuality of Care
BehaviouralAppreciative inquiry
EnvironmentalVectorsWater
EnvironmentalVectorsWater
Supply
Demand
HH or communityAgents of changeWomens groups
Traditional health systemsEquity
Rural 15% hospital deliveries
Governance
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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%
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Principles of essential newborn careAir/breathing/resuscitationWarmthEarly breastfeedingHygieneKeep with motherTreat illness and infection promptly
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0
100
200
300
400
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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
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Principles of essential obstetric careAntenatal careHygiene Birth preparedness to avoid delaysSkilled attendantAccess to emergency obstetric carePostnatal care
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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
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On the road
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Maternity access
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How do we know whether our policies and programmes are
working?
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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
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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
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TBA
VHW
60% fall in NMR
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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
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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
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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
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77g increase in birth weight
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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
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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
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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
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Appreciating what staff (and mothers) do in difficult circumstances
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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
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Dr T Sundararaman from State Health Resource Centre, Chhattisgarh
Activities of mitanins
Agents of change for demand side intervention
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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
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Supply Demand
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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
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Problem Identification
Planning together
Implementation
Participatory evaluation
Year 2
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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
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$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
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One woman facilitator
8% MWRA in groups
37% newly pregnant women in groups
?% non-group pregnant women
Amplification
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Scepticism about findings
Will it work elsewhere?
Need several studies to change policy
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Bangladesh
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India, Jharkand
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India, Mumbai
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Nepal MIRA Dhanusha trial
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Malawi
Lancet Sept 30 2006, Rosato, Mwansambo et al.
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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