Presentation_Jurczynska - Catalyzing Investments in RMNCAH at the Community L...
Dory Storms_Baqui_10.11.12
1. Neonatal Health and
Sur vival
Generating Evidence and Translating
into Practice
Abdullah Baqui
Pr ofessor
Depar tment of Inter national Health
Johns Hopkins Bloomber g School of Public
Health
Cor e g roup meeting, 11 October 2012
2. Baqui Newborn Research Activities
• Develop and test feasible, context-specific, and
cost-effective interventions
• Use evidence to influence policies and
programs
• Assist ministries, NGOs, and development
partners to scale up tested interventions
through real time monitoring, evaluation and
implementation research
4. PROJAHNMO in Bangladesh: Context
• Partnership of Bangladesh MOHFW,
ICDDR,B, Shimantik, CHRF, and Johns
Hopkins University
• Established in 2001 to improve
new-born and maternal health
• Study Site: Sylhet district in about
560,000 population
• Facility delivery rate = 9%
• Skilled attendance at delivery = 13%
• NMR ~ 50/ 1,000; 50% attributed to
infections. Funded by USAID, SNL/Save the Children, Gates Foundation, NIH
5. Projahnmo-1: Interventions
• Between 2001-2006, developed, implemented and
evaluated a package of community-based MNH
interventions
• Package components included promotion of
• ANC, TT, IFA supplementation
• Birth preparedness including promotion of facility
delivery or skilled attendance at delivery
• Recognition of maternal danger signs, and care
seeking
• Essential newborn care
• Recognition of newborn danger sign, care seeking
6. Projahnmo-1: Service
Delivery Strategies
• One CHW/ 4,000 population
• 2-monthly home visits to identify pregnant women
• 2 antenatal home visits to promote the interventions
• 3 postnatal home visits (days 1,3,7 of births) to promote
newborn care, assess babies and manage sick babies
• CHWs were trained to treat suspected infections if
referral was not feasible
7. Projahnmo-1: Key Findings
• Home based delivery of a community-based package of
MNH interventions reduced NMR by 34% (Baqui et al.,
Lancet, 2008)
• Early postnatal home visits on day 1 or 2 of life by a trained
CHW was associated with 2/3rd lower NMR (Baqui et al,
BMJ, 2009)
• Early identification and management of new-born infection,
either at first level health facility or at home, had additional
impact on neonatal mortality (Baqui et al, PIDJ, 2009)
8. Projahnmo: Policy and Program
Impact
• MOHFW/Bangladesh developed a national
neonatal health strategy
• USAID/Bangladesh supported scale up in two
districts
• UNICEF/Bangladesh supported implementation
through local NGOs in 6 additional districts
• WHO/UNICEF issued a joint statement
recommending home visits for the newborn
child as a strategy to improve survival
10. RACHNA Evaluation: Overview
• A program at scale, covered ~100 million people in 8 states of
India
• Integrated program addressed:
– Maternal health
– Child health and nutrition including community-based
newborn care
– Family Planning, HIV/AIDS
• A facilitation program, implemented through two existing
government programs: ICDS and MoHFW
• Newborn package was similar to Projahnmo
• Used a quasi-experimental design
• Conducted annual assessments to provide feedback to
implementers so that program strategies can be adjusted
11. JHU/IIP’S STEPWISE
EVALUATION DESIGNS
To what extent can the impact
To what extent can the impact
be attributed toto the program?
be attributed the program?
for program improvement
IsIs there an impact on health and
there an impact on health?
for program improvement
nutrition?
Systematic feedback
Systematic feedback
Have adequate levels ofof effective coverage
Have adequate levels effective coverage
been reached inin the population?
been reached the population?
Are these services being used by the population?
Are these services being used by the population?
Is there continuity of care?
Are adequate quality services being provided?
Are adequate quality services being provided?
atat health facility level?
health facility level?
atat community level?
community level?
Are the interventions and plans for delivery technically sound and
Are the interventions and plans for delivery technically sound and
appropriate for the epidemiological and health system context?
appropriate for the epidemiological and health system context?
12. RACHNA Evaluation – Results and
interpretation
• No reduction in neonatal mortality – why?
• Modest increase in coverage
• A postnatal home visit within 3 days of delivery was
associated with significantly lower neonatal mortality
• Modelling of data suggested that increasing coverage
of postnatal home visit to 90% could reduce neonatal
mortality rate by 30%
• Increasing coverage, sustaining quality, and achieving
health impact in large programs remain a challenge
13. Optimizing integrated MNCH
services in Tanzania
• MOHSW/ Tanzania implementing an integrated MNCH
program emphasizing postpartum care with support from
JHPIEGO
• The program components include:
Development of a CHW program to provide behavior
change communication and selected services
Capacity building of selected district hospitals and
health centers
• Conducting evaluation in partnership with MoHSW,
Tanzania, Jhpiego, and Muhimbili University
Funded by USAID through HRCI cooperative agreement
14. Evaluation objectives
• To monitor and document the implementation of the
MNCH intervention package
• To provide feedback to program managers on barriers
to access, coverage, and quality of essential MNCH
interventions to facilitate adjustment of program
strategies
• To assess effectiveness and cost of the final
intervention package; and
• To disseminate lessons learned and provide policy
support to facilitate scale up to other Regions of
Tanzania
15. Year -1 Evaluation Activities
• Conducted baselines assessments using mixed
methods:
– Household Survey
– CHW surveys
– Facility assessments
– In-depth interviews
• Synthesized data and lessons learned
• Shared in a participatory workshop and developed
recommendations for the program
17. Barriers to care seeking
• Supply side:
– Inadequate human resources, supervision, supplies
– Inadequate quality of care, both technical quality as well
as disrespectful behavior by providers
• Demand side
– No systematic community-based program
– Distance to facility, lack of transport, cost
18. Recommendations
• Continued focus on improving quality
• Develop strategies for overcoming barriers to care
seeking e.g, address transport and other costs
• Build linkages between the community and facility
• Formalize the CHW cadre, including recruitment criteria,
training, and service packages
• Develop sustainable support systems for CHWs, with a
focus on supportive supervision and create incentives
for CHWs work
19. Concluding Thoughts
• The burden of newborn and maternal mortality is still very
high
• More than half of these deaths can be prevented by
scaling up evidenced based interventions
• Successful implementation requires strengthening health
system including real time monitoring/ evaluation and real
time use of data to adjust program strategies
• Close partnership between program managers and
researchers and use of implementation/evaluation
research can help us quickly attain the MDG goals
20. Concluding Thoughts
• Many lives are at stake
• We know what needs to be done
• Deliver evidenced-based
interventions at scale with high
coverage and quality to reduce
stagnated neonatal mortality
Thank you
Notas do Editor
Thank you Dean Klag for your kind introduction. Distinguished colleagues and guests, good afternoon. My talk will be a reflection of my research work since I came to the school about 10 years ago and what I see as opportunities for future research building on the work to-date. During the last decade, my work was largely focused on design and implementation of evidence informed community-based newborn interventions. The purpose was to improve newborn survival in the resource poor settings of South Asia and sub-Saharan Africa. The goal of my research was to contribute to the schools mission to save lives of millions of newborn around the world.
The activities can be grouped in to three categories: 1) We develop and test feasible, culturally appropriate, and cost-effective interventions or packages of interventions including design and evaluation of service delivery strategies. The types of research include assessment of efficacy or effectiveness using randomized trials or quasi-experiments. 2) We assist ministries, NGOs, and development partners to scale up tested interventions through evaluation and implementation research. 3) We use evidence to influence policy & programs. Although I listed them sequentially, these are not necessarily sequential steps. Dissemination, policy and program influence is an ongoing activity. In all our project, there is some form of local TAG or TAC compromised of colleagues from ministries, local research groups, academia, and community representatives with who we meet every few months. Therefore, there is a constant exchange of ideas that helps maintain the relevance of the research and increase local ownership
Now let me talk about a project that we developed in partnership to generate evidence for new interventions. The project is known as Projahnmo which is a Bangla word meaning generation. Save the Children, US and Gates Foundation developed a video on Projahnmo project which is available in the web.
Projahnmo Dissemination 10 Dec 2006 Presentation #4
Projahnmo Dissemination 10 Dec 2006 Presentation #4
Projahnmo Dissemination 10 Dec 2006 Presentation #4
Now let me provide an example of the second stream of research i.e., evaluation research to improve program performance and effectiveness. We evaluated a community based newborn program implemented by CARE/India as part of an integrated program named as RACHNA
RACHNA was a program at scale, covered ~100 million people in 8 states of India. It was an integrated program that addressed: Maternal health Child health and nutrition including community-based newborn care and Family Planning, RTI/STI/HIV/AIDS It was a facilitation program where CARE/India’s inputs were in planning, tainting, coordination, and monitoring; the program was implemented through two existing government programmes: ICDS and MoHFW The newborn package was similar to Projahnmo except there was no home treatment for newborn infections We used a quasi-experimental design. In addition to baseline and endline surveys, we conducted interim assessments to provide feedback to implementers so that program strategies can be adjusted
There was no reduction in neonatal mortality mainly because the intervention coverage remained low. Those who received the intervention benefitted. A postnatal home visit within 3 days of delivery was associated with significantly lower neonatal mortality. Modelling of data suggested that increasing coverage of postnatal home visit to 90% could reduce neonatal mortality rate by 30%. This evaluation research suggests that increasing coverage and achieving health impact in large programs remain a challenge. Successful implementation requires attention to results and not just processes.
Overview: Presenter: Should we include Study dates with regard to funding or the actual study start date?
Of ~ 1,971 women, 87% received 1 or more ANC. However, only 68% received 4 or more ANC. This drop of 32% in utilization of multiple ANC services could reflect multiple issues: There is delayed timing of ANC 1 meaning women obtain this service initially too late in the life span of their pregnancy and effectively ‘time out’ … There is a missed opportunity of emphasis among women that do come to the facility for emphasizing the importance of multiple visits. When we move along the continuum of care, we see that 66% of women report giving birth in a health facility – a figure not too far below the 68% coverage for 4 + ANC. However, for postpartum / postnatal care, there is a marked decline as only 22% of individuals receive this service. If we progress further into the postpartum period and too look at family planning, we see that 34% of recently delivered women report “Current USE of any modern contraceptive”. In the next slide we’ll look at the linkages between these services.