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.
Neonatal Health and Sur vivalGenerating Evidence and Translating into Practice Abdullah Baqui Pr ofessor Depar tment of Inter national HealthJohns Hopkins Bloomber g School of Public Health Cor e g roup meeting, 11 October 2012
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
A Research Partnership toGenerate EvidencePROJAHNMO inBangladesh 3
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
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
Projahnmo-1: ServiceDelivery 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
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)
Projahnmo: Policy and ProgramImpact• 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
Evaluation/ImplementationResearch to Improve Program Performance and Effectiveness Evaluation of RACHNA Program in India (2002- 2006)
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
JHU/IIP’S STEPWISEEVALUATION 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?
RACHNA Evaluation – Results andinterpretation • 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
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 UniversityFunded by USAID through HRCI cooperative agreement
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
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
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
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
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
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