Lives Saved Analyses for Child Survival Projects: Using LiST to Estimate the Impact of Maternal, Newborn and Child Health Interventions

Lives Saved Analyses for Child Survival Projects: Using LiST to Estimate the Impact of Maternal, Newborn and Child Health Interventions Debra Prosnitz, MPH; Rebecca Levine, MPH; James Ricca MD, MPH; and Ingrid Friberg, PhD

Lives Saved Tool
Beginnings of LiST :
Inspired by the “Bellagio” modeling exercise which served as the basis for the data in the Lancet Child Survival Series
Goal of LiST :
To promote evidence-based decision making for planning the appropriate expansion of maternal, neonatal and child health interventions in low-income countries, and evaluation and estimation of Lives Saved (past and present).
Objectives of LiST :
To estimate additional number of lives saved when scaling up key interventions and to provide a user-friendly tool for child survival planning in developing countries.

LiST
The Lives Saved Tool
A multi-cause model of mortality
Predicts changes in
Under 5, infant and neonatal mortality rates and deaths
Maternal mortality ratios and deaths
Causes of death
Using
Country specific health status
Baseline Child Mortality from UNICEF
Child and maternal health intervention coverage levels
i.e. ORS, facility delivery, etc.
Effect sizes of interventions based on the best available evidence

How does LiST work
Built into a demographic package
DemProj in Spectrum
Links to other Spectrum modules
AIM for AIDS
FamPlan for Family Planning
Cohort-based model
Children cannot die multiple times
Impacts can be lagged to a later age period
Risk factors affect probability of mortality

General Framework of the Model Demographic estimates and projections UN Pop/Spectrum Number of Child and Maternal Deaths Deaths by Cause WHO/UNICEF Country estimates
Deaths averted
By cause
By intervention
Intervention Impact C1 C2 C3 C4 … Int1   Int2  Int3  
Intervention Coverage
Current (database)
Future (user-defined)
Health Status
% stunted
Malaria prevalence
Vit A deficiency
Zinc deficiency
WHO Database
Stunting

Interventions Included
Proximal factors
Not distal (i.e. poverty, lack of education)
Work through health programs
Not included: income, education and crowding, etc.
Sanitation is the exception
Feasible in a low income country
68 priority countries with highest MNCH mortality
Cause-specific evidence of effect
Research studies or systematic reviews
Delphi method if research is impossible (i.e. CEmOC)
Updated every year

Types of Interventions
Maternal, neonatal, child
Periconceptual, antenatal, birth, immediate postnatal, child
Preventive, curative
Nutritional, vaccination, water/sanitation, treatment
Risk factors: Cause-of-death specific
Immediate, time-lagged
External (family planning, AIDS), internal (all others)

Peri-conceptual Interventions
(Family planning (birth spacing))
Folic acid supplementation or fortification
Abortion services
Antenatal Interventions
Syphilis detection
Calcium supplementation
Multiple micronutrient supplementation
IPTp malaria (or ITN use)
Tetanus toxoid
Balanced energy supplementation
Case management of maternal malaria

Care/Interventions During Child Birth
Antenatal corticosteroids for preterm labor
Antibiotics for pPRoM
Essential care for all women and immediate ENC (institutional)*
Basic emergency obstetric care*
Comprehensive emergency obstetric care*
Active management of the 3rd stage of labor - AMTSL
Newborn resuscitation (institutional & home)
Clean practices and immediate ENC (home)

Preventive Interventions
Kangaroo mother care
Routine postnatal care (healthy practices & illness detection)
Breastfeeding promotion
Complementary feeding
Education only
Education and supplementation
Insecticide treated materials
Vitamin A for prevention
Zinc for prevention
Improved water source within 30 minutes
Water connection in the home
Improved excreta disposal (latrine, toilet)
Hand washing with soap
Hygienic disposal of children’s stools
Rotavirus vaccine
Measles vaccine
Hib vaccine
Pneumococcal vaccine
DPT3 vaccine
Polio vaccine
BCG vaccine

Curative Interventions
Case management of serious neonatal illnesses
Oral antibiotics
Injectable antibiotics
Full supportive care: oxygen, IV fluids, IV antibiotics)
ORS for diarrhea
Antibiotics for dysentery
Zinc for treatment of diarrhea
Case management of pneumonia
Vitamin A for measles treatment
Therapeutic feeding
Antimalarials
(Cotrimoxazole for HIV)
(ART for children)

NOT Included in the Model
Education
Motivation
Gender issues
Economic status
Emergencies (i.e. famine, flooding)
Delivery mechanism
Only as relates to total population coverage
Quality of care
Can somewhat take this into account
Assumption: Several of these factors are DISTAL factors which MAY work through COVERAGE changes…thus MAY already be in the model

Interventions NOT in LiST
Magnesium sulfate
De-worming
IPTi
Breastfeeding initiation within 1 hour
Birth spacing benefit
Treatment of water in the home
Iron (or iron-folate) supplementation

Data Needed to Run LiST
Country-Specific
Population data and trends
Default: UN Population Division 1950-2050 (DemProj)
User entered (district) data
Cause of death structure
Default: WHO/UNICEF (2000-2003)
User entered data
Intervention coverage
Population based data
Default: Childinfo.org or DHS/MICS (closest to 2003)
User entered data
Global
Intervention Efficacies
User entered data

Building Blocks of the Model
Preventions
Treatments
Risk factors
Using Multiple interventions
Two Preventions (or Risk Factors):
Proportional impact by coverage/effect size
Calculated on residual deaths
No double counting
Preventions and Treatments:
Enter prevention(s), then treatment(s)
Deaths not already averted

Age Groups
Neonatal
< 1 month
Post-neonatal
1-5 months
6-11 months
12-23 months
24-59 months

Multiple Interventions in LiST
In the context of other interventions
In the context of the baseline health status
In the context of changes over time
You create your own package!!!

Odds and Ends
Effect sizes do not vary on based on either coverage of disease prevalance
Exception: *Herd Immunity*
Some components are grouped
Multiple nutrition impacts

Groupings
Antenatal Care
Components
Case management, syphilis
Child Birth Care
Facility and Home based deliveries
Components
Corticosteroids, antibiotics, labor monitoring/ emergency obstetric care, resuscitation, clean delivery
Water
Components
Water within 30 minutes, water in the home

Nutrition Impacts
Direct impact
Therapeutic feeding
Balanced energy supplementation
Multiple micronutrient supplementation
Complementary feeding (education ± supplementation)
Breast feeding prevalence/promotion
Zinc supplementation
Water and sanitation
Indirect impact
Water and sanitation – via diarrhea
IPTp – on IUGR
Zinc – via diarrhea
None
Vitamin A supplementation

Stunting Zinc Diarrhea incidence IUGR Appropriate Complementary Feeding Complementary feeding education and/or supplementation Previous Stunting

Malaria Mortality Disease Specific Treatments Disease Specific Preventions Risk factors ITN/IRS Antimalarials Stunting

Stunting Post-Neonatal Diarrheal Mortality Rotavirus vaccine Vitamin A Zinc Water/Sanitation (5) Zinc Antibiotics for dysentery ORS Disease Specific Treatments Disease Specific Preventions Risk factors IUGR Syphilis detection and treatment IPTp Maternal energy and/or micronutrient supplementation Zinc Complementary Feeding Complementary feeding education and/or supplementation Diarrhea incidence Improved H 2 O source within 30 minutes Hand washing with soap Water connection in the home Improved excreta disposal (latrine, toilet) Hygienic disposal of children’s stools Distant Factors Breast Feeding Breast Feeding Promotion

Advanced Topics FamPlan and AIM in LiST
LiST can be linked to AIM (HIV) and FamPlan (Family Planning) Spectrum modules
To examine combined, estimated, impact multiple models must be compared.
Please contact a LiST trainer to assist with any LiST, FamPlan, or AIM integration

What LiST Is, What LiST Isn’t
Is
Multi-cause mortality model
Mathematic model
Models coverage impacts
Potential impact assessment
National or sub-national planning tool
Discussion points
Evidence-based
Isn’t
Natural history model
Truth
Probabilistic model
Detailed costing or planning tool
Bottlenecks, budgeting
Exhaustive

Projection of Additional Lives Saved
Projections of additional lives saved are based on the assumption that all other coverage levels remain the same!!!
This is important to keep in mind for mature interventions (i.e. Immunization)
We do not want projections to inadvertently make the case for decreasing funding/coverage for these interventions

Some Limitations
Data availability
If no baseline, can’t evaluate impact accurately
Data quality
Sensible scale up targets
Feasible, acceptable, funds available
EX: Project presented to MOH a plan to scale up handwashing from 3% to 80%
Interventions included in software

Some Limitations: Maternal Health Intervention Assumptions
Because of the much smaller numbers of maternal deaths & the continuing work to determine the impact that some interventions have on maternal survival, LiST may not be the best tool to weigh the relative value of different investments in maternal survival
MH interventions included in LiST are packages that are only effective in reducing mortality if all services are provided at quality

LiST Validation
“ How do you know that this works?”
“ How can it be used in reality?”

Neonatal Package Modeling
Source: Friberg, et al. Comparing modelled predictions of neonatal mortality impacts using LiST with observed results of community-based intervention trials in South Asia. International Journal of Epidemiology 2010; 39: i11-i20

ACSD Countries
Ghana (1% underestimate) - Good
Mali (10% underestimate) – OK
Predominantly post-neonatal interventions
Data from DHS and other sources
Adequate correlation

Modeling Mortality Rates and Equity

How Can LiST be Used?
Planning, Evaluation, Advocacy
Strategic planning
Which interventions are necessary to reduce mortality? (maternal, neonatal, under-5)
By how much will project targets reduce mortality?
Evaluation and intermediate-term follow-up
What is the impact of observed coverage changes?
Evaluation of historic trends (i.e. multiple DHS/MICS/KPC surveys)
Predict estimated lives saved (past and future)
How many lives were saved, total and by intervention, over the course of your project (in your project area)?
How many deaths remain after intervention scale ups?

How Has LiST Been Used?
Globally
Global Action Plan for Pneumonia
‘ Impatient Optimist’ speech by Bill Gates
Regionally
ASADI, by Saving Newborn Lives
Country level
Catalytic initiative: to guide planning and priority setting
Malawi, Ghana
Sub-National
Lives Saved by CSHGP projects

Who Uses LiST ?
United Nations
WHO/CAH
UNICEF-ESARO
Development Partners
USAID
BMGF
CIFF
CIDA
Save the Children
MCHIP partners
PMI
JSI
Other organizations
Abt
JHSPH
ICF Macro
Countries
Catalytic Initiative
Malawi
Burkina Faso
Ghana
Doris Duke Foundation

Future Directions for LiST
Add the new CHERG Cause of Death structure - 2008
Birth spacing benefit of family planning
Additional costing tie-ins
Finalization of CHOICE based costing tool
Links to the fiscal and bottleneck portions of MBB
Updated interventions – continuous
Research, Reviews, Model updated
Documentation – to be published in the winter
‘ Research’ version
To predict the impact of future developments

Who Owns LiST ?
WHO?
UNICEF?
US Fund for UNICEF?
CHERG?
Gates Foundation?
Futures Institute?
JHSPH?
INDEPENDENT

LiST Contributors Institute for International Programs

How to Get LiST
FREE
www.futuresinstitute.org
www.healthpolicyinitiative.com/index.cfm?id=software&get=Spectrum
www.jhsph.edu/iip
Languages
English, French, Spanish, Portuguese
Manuals
English, French, Spanish, Portuguese
Contact
Ingrid Friberg - ifriberg@jhsph.edu

Lives Saved Analyses for Child Survival Projects: Using LiST to Estimate the Impact of Maternal, Newborn and Child Health Interventions

by jehill3 on Apr 28, 2010

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Lives Saved Analyses for Child Survival Projects: Using LiST to Estimate the Impact of Maternal, Newborn and Child Health Interventions — Presentation Transcript