1. 1 OU Mar. 2009 Child survival – how many deaths can we prevent and at what cost?

2. 2 OU 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

3. 3 OU Mar. 2009 Mortality by cause Interventions Impact on mortality Model A model for linking interventions to Impact on under-5 mortality Resources

4. 4 OU Mar. 2009 Mortality by cause Impact on mortality Model Resources Interventions A model for linking interventions to Impact on under-5 mortality

5. 5 OU Mar. 2009 24 countries in which over 90% of under-5 deaths occur Neonatal division Asphyxia - 29% Sepsis - 25% Tetanus - 7% Prematurity - 24% (Other is 15%)

6. 6 OU Mar. 2009 Mortality by cause Impact on mortality Model Resources Interventions A model for linking interventions to Impact on under-5 mortality

7. 7 OU 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

8. 8 OU Mar. 2009 Interventions by cause - diarrhoea Exposure to diarrhoea Diarrhoea Survive Die Breastfeeding Complementary feeding Treatment Zinc Future: rotavirus vaccine Vitamin A Antibiotics for dysentry Oral rehydration therapy Zinc Water/San/Hygiene Prevention

9. 9 OU Mar. 2009 Interventions, neonatal - prematurity Pregnant Premature Survive Die Insecticide-treated materials* Intermittent preventive therapy Newborn temperature management PreventionTreatment Antinatal steroids Antibiotics for premature rupture of membrane * Indoor residual spraying may be used as an alternative

10. 10 OU Mar. 2009 Mortality by cause Impact on mortality Model Resources Interventions A model for linking interventions to Impact on under-5 mortality

11. 11 OU 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

12. 12 OU Mar. 2009 For the majority of calculations the proportionate reduction of deaths when intervention coverage is increased from the current value (p c ) to target (p t ) is = A f E f (p t - p c )/(1 – p c E f ) where E f is the efficacy of the intervention and A f is the fraction of deaths affected by the intervention. Lancet model – calculation of deaths averted

13. 13 OU Mar. 2009 Lancet model – parameters

14. 14 OU Mar. 2009 Mortality by cause Impact on mortality Model Resources Interventions A model for linking interventions to Impact on under-5 mortality

15. 15 OU 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

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17. 17 OU Mar. 2009

18. 18 OU Mar. 2009

19. 19 OU Mar. 2009

20. 20 OU Mar. 2009 Mortality by cause Interventions Impact on mortality Model Resources A model for linking interventions to Impact on under-5 mortality

21. 21 OU 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

22. 22 OU Mar. 2009 Source: Bryce et al, Can the world afford to save the lives of 6 million children each year? Lancet June 2005

23. 23 OU Mar. 2009 Source: Bryce et al, Can the world afford to save the lives of 6 million children each year? Lancet June 2005

24. 24 OU Mar. 2009 Source: Bryce et al, Can the world afford to save the lives of 6 million children each year? Lancet June 2005

25. 25 OU Mar. 2009 Child mortality reduction: effects of varying assumptions on additional running costs Variable assessedLowHighLowHigh Country specific cost of community delivery agent relative to cost of a midwife (originally 75%) 50%100%43115955 Drug costs-25%+25%45985669 Existing intervention coverage level in year 2000 +25%-25%42106374 All three variables31118083 Variable value Additional annual running cost (US $ millions) Individual country costs and situations differ widely Source: Bryce et al, Can the world afford to save the lives of 6 million children each year? Lancet June 2005

26. 26 OU 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

27. 27 OU Mar. 2009 Experiences in Africa

28. 28 OU 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

29. 29 OU Mar. 2009 The Review 2004-2005 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

30. 30 OU Mar. 2009 Context

31. 31 OU Mar. 2009 Interventions that have the most direct impact on the child—and could make the most difference… Prevention By intervention

32. 32 OU Mar. 2009 Treatment

33. 33 OU Mar. 2009 By location of intervention Health 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 ORT Partial coverage 60% malaria interventions (Abuja target) 70% excl. breastfeeding and all others Percent of total deaths preventable by groups of location associated interventions

34. 34 OU Mar. 2009 Findings

35. 35 OU Mar. 2009 Children exclusively breastfed up to age 6 months in five ESAR sites (baseline and follow-up) Breastfeeding Improving breastfeeding practices could prevent the deaths of 233,000 children in ESAR.

36. 36 OU 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% Complementary feeding 7 %  Feeding practices improved, but quality of food decreased Vitamin A3 %  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% Antimalarials8 %  Children with fever treated with SP at home increased from 18% to 22% Interventions can improve multiple practices

37. 37 OU 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

38. 38 OU 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) Three intervention packages 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

39. 39 OU 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) 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.

40. 40 OU 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) Evaluation questions Coverage 1. Were there changes in the ACSD “high-impact” districts? 2. Were these changes greater than in the comparison area? Impact 3. Were there changes in nutrition and mortality in the ACSD “high- impact” districts? 4. Were these changes greater than in the comparison area? Attribution 5. Is it plausible to attribute the impact found to ACSD?

41. 41 OU 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) 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

42. 42 OU 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) Data sources: All existing data that met quality standards

43. 43 OU 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) 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 mortality Community tx of pneumonia not included at scale ACTs 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

44. 44 OU 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) Coverage for EPI+ interventions before and after ACSD, in HIDs Before ACSD After ACSD Key BeninGhana Mali Increases in coverage across the board in Ghana and Mali; Benin achieved increases for vitamin A and ITNs.

45. 45 OU 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) Coverage for IMCI+ interventions before 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. BeninGhana Mali

46. 46 OU 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) Coverage for ANC+ interventions before and after ACSD, in HIDs Before ACSD After ACSD Key Ghana and Mali improved care for childbearing women; delivery of TT and postnatal vit A benefited from EPI system in Mali. BeninGhana Mali

47. 47 OU 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) Research question #1: Increases in coverage in ACSD HIDs?

48. 48 OU 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) Under-five mortality in the ACSD HIDs Research question #3:

49. 49 OU 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) Research question #4: Under-five mortality in the ACSD HIDs and national comparison areas

50. 50 OU 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) 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

51. 51 OU 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) 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

52. 52 OU 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) 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

53. 53 OU 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) 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.

54. 54 OU Mar. 2009 Where to from here?

55. 55 OU 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) Lives Saved Tool (LiST) Target users The 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

56. 56 OU 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) Immediate future? Numerous international health initiatives – many building on the Lancet/ACSD approach

57. 57 OU Mar. 2009

58. 58 OU 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) 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

59. 59 OU Mar. 2009