1. Community-based Approaches to Improving
Reproductive, Maternal, Neonatal and Child
Health: Current Status of the Evidence
Henry Perry, Department of International Health
Spring CORE Group Meeting, 8 May 2014

2. Outline
• Rationale for the review
• Components of the review process
• Findings
• A framework for improving RMNCH through
community-based approaches
• The way forward

3. Rationale for the Review
• Rapidly expanding evidence base
• Increasing interest in CBPHC
• Need to begin to develop a more holistic
(integrated) approach to programming
• The follow-on to USAID-supported MCHIP
(RMNCH) is now starting up

4. Components of the Review
• General review of any (peer-reviewed or grey)
literature on community-based approaches to
provision of RMNCH services (465 articles)
• Review of projects/programs/field studies that
assessed the effectiveness of CBPHC in
improving child health (476 assessments) or
maternal health (119 assessments)
• Factors related to effective CHW programming
and national CHW program case studies

5. Review Process
• Evidence-based review of effectiveness of
CBPHC in improving child health
• Large-scale CHW program review
• Evidence-based review of effectiveness of
CBPHC in improving maternal health
• Broad literature review of promising
approaches to RMNCH

6. Findings: General Literature Review

7. Newly Emerging Interventions for
Community-based Delivery
• Chlorhexidene umbilical cord care
• Misoprostol for prevention of PPH
• Zinc + ORS
• iCCM
• Participatory women’s groups
(PLA, Care Groups)
• Home-based neonatal care (+ PP FP)
• HIV/AIDs prevention, detection, treatment
(particularly for PMTCT)

8. Mainstay Interventions for
Community-based Delivery
• Immunizations
• Vitamin A supplementation
• Breastfeeding/appropriate
complementary feeding
• Maternal health (multiple
micronutrients, nutritional
supplementation during
pregnancy, ANC, clean
delivery, delivery by a skilled
attendant, promotion of
facility-based delivery)
• CCM of childhood
pneumonia
• Prevention and treatment
of malaria (ITNs, IPT, CCM)
• CMAM

9. Broader Reproductive Health Interventions that
Can Be Provided through Community-based
Approaches
• Family planning
• Support for women living with AIDS
• Cervical cancer screening and treatment
• Harm reduction from unsafe abortion
• Detection and treatment of syphilis

10. Evidence from Integrated Programs
• PVO child survival projects
• Care Group projects
• Jamkhed/India, Hospital Albert
Schweitzer/Haiti, Matlab/Bangladesh,
SEARCH/India
• BRAC/Manoshi/Bangladesh

13. Evidence from Country Successes
• Bangladesh
• Nepal
Lancet
2013

14. Ethiopia
Brazil

15. Strengthening Community-based
Service Delivery
• Community-based facilities
• Informal and traditional providers

16. Community Engagement and
Community Partnerships
• Examples
– Community-Directed Interventions
• Initially for neglected tropical diseases but now moving
into RMNCH
• Descriptions of processes
– Manoshi

18. Practical Findings from Operations
Research
• Need to focus on main causes of mortality in order to
demonstrate a decline in mortality
– Evaluation of UNICEF West Africa programs with evidence of
increased coverage but no mortality impact (Bryce et al., Lancet,
2010)
– Evaluation of home-based neonatal care program in Bangladesh
(Darmstadt et al., 2010)
• Need to achieve a certain intensity of women’s
participatory groups for PLA
– Program intensity in Ethiopia related to program outcomes
(Karim et al., PLOS 2013)
– For PLA groups, need to reach 30% of mothers (Fottrell et al.,
JAMA Pediatrics 2013)
• Lack of supervision and logistical support are pervasive

19. Financial Aspects
• Innovative approaches to financing
• Cost-effectiveness limited except for some on
a few specific interventions

20. Monitoring and Evaluation
• Practical approaches to assessing effectiveness of
large-scale programs
• Monitoring coverage
• LiST
• Mortality assessment (measurement of changes
in mortality rate, verbal medical and social
autopsy)
• Strengthening M&E of large-scale CHW programs
(with transparent independent assessments
every 5 years or so)

21. Emerging Issues
• Mental health for WRA
• Gender-based violence (including FGM)
• Other diseases of WRA (HIV/AIDS, TB, malaria,
chronic diseases)
• Injuries

22. Cross-cutting Themes
• Urban health
• Scaling up programs
• Equity
• Health systems strengthening
• RMNCH in post-disaster relief and settings
with political conflict

23. Policy and Philosophical Issues
• The role of NGOs in fostering community
engagement, community mobilization,
community-based service delivery, training
and support of CHWs
• Restoring a better balance between vertical
and horizontal programming
• Strengthening the effectiveness of frontline
workers and large-scale CHW programs
• Creating a more favorable policy environment

24. Conceptual Approaches
• CBIO
• Aggressive home visitation with early
treatment of childhood illness

25. Findings from Effectiveness Review

26. Practical Program Strategies
• Intervention delivery
– Home visits
– Participatory women’s groups
– Community-case management
– Provision of services by mobile teams based at
peripheral facilities

27. Strategies for Village-wide Community
Empowerment/Mobilization/
Demand Creation
• Advocacy meetings with community leaders
• Promotion and support of village health committees, village
development committees, and sanitation committees
• Community-wide meetings
• Community-directed interventions
• Village health days/malaria awareness days, etc.
• Health talks at Friday mosque gatherings, church meetings, etc.
• Sharing locally obtained health-related data with the community
• Involving men and older family members (e.g., mothers-in-laws)

28. Strategies for Community Empowerment/
Mobilization/Demand Creation in Groups
• Formation and training of women’s groups (community health
clubs, pregnant women’s support groups, mothers’
centers/mothers’ committees, Care Groups, PLA Groups, self-
help groups, women’s action groups, counseling and support
groups)
• Formation of parent committees
• Formation of adolescent groups
• Formation of farmers’ clubs
• Conditional cash transfers to eligible mothers
• Savings and loan groups (microcredit)

29. Health System Strengthening Approaches
• Training of staff – frontline workers, CHWs, TBAs
• Develop or upgrade peripheral facilities, strengthen quality of
care
• Strengthen drug supply chain
• Strengthen linkages between CHWs and peripheral facilities
• Strengthen referral system

30. Strategies for Program Design, Identification
of Target Groups, Surveillance
• Formative research/appreciative inquiry/PLA/stakeholder
analysis
• Village registers (pregnancies, pregnancy outcomes, births,
deaths, TB patients)
• Verbal autopsies
• Client-held cards (maternal health cards, road-to-health cards,
child health cards, immunization cards)
• KPC surveys

31. Educational Strategies
• Peer-to-peer counseling
• Visual aids
• mHealth
• Skits, stories, games
• Targeting grandmothers
• Positive deviance inquiry/identifying strong community-level
workers to support others not as strong

32. Review of Large-scale Community
Health Worker Programs

37. • The final version will be available on the
MCHIP website next week:
http://www.mchip.net/chwreferenceguide

38. Creating a Framework for Sustainable
Improvements in RMNCH at Scale
through CBPHC

39. Community engagement, etc.

43. Paradigm Shift
• Approaching the community as a resource and
partner, not a target of programs or passive
recipient of services
• Investing in CBPHC as the priority for health
systems strengthening and improving
population-level health

44. The Way Forward
• Entry points
– Policy (e.g., for task shifting, etc.)
– Creation of “friendly” environment for CBPHC,
community engagement and NGOs
– Supporting the development and assessment of
“model” integrated RMNCH programs
– Supporting literature reviews/analyses of existing data
– Continued research on current and new interventions
– Operations research/translating policy and research
into action/implementation research/efficacy to
effectiveness research/research on CHW programs
– Replication and scaling up of promising approaches

45. Acknowledgments
• MCHIP/USAID
• Jim Ricca, Nazo Kureshy and others at USAID
and MCHIP who supported this work
• Working Group on Community-based Primary
Health Care of the International Section of the
American Public Health Association
• USAID, UNICEF, WHO, World Bank and Future
Generations for support of the effectiveness
review