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Using li st_to_estimate_impact

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Using li st_to_estimate_impact

  1. 1. 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
  2. 2. Lives Saved Tool <ul><li>Beginnings of LiST : </li></ul><ul><li>Inspired by the “Bellagio” modeling exercise which served as the basis for the data in the Lancet Child Survival Series </li></ul><ul><li>Goal of LiST : </li></ul><ul><li>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). </li></ul><ul><li>Objectives of LiST : </li></ul><ul><li>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. </li></ul>
  3. 3. LiST <ul><li>The Lives Saved Tool </li></ul><ul><ul><li>A multi-cause model of mortality </li></ul></ul><ul><li>Predicts changes in </li></ul><ul><ul><li>Under 5, infant and neonatal mortality rates and deaths </li></ul></ul><ul><ul><li>Maternal mortality ratios and deaths </li></ul></ul><ul><ul><li>Causes of death </li></ul></ul><ul><li>Using </li></ul><ul><ul><li>Country specific health status </li></ul></ul><ul><ul><ul><li>Baseline Child Mortality from UNICEF </li></ul></ul></ul><ul><ul><li>Child and maternal health intervention coverage levels </li></ul></ul><ul><ul><ul><li>i.e. ORS, facility delivery, etc. </li></ul></ul></ul><ul><ul><li>Effect sizes of interventions based on the best available evidence </li></ul></ul>
  4. 4. How does LiST work <ul><li>Built into a demographic package </li></ul><ul><ul><li>DemProj in Spectrum </li></ul></ul><ul><li>Links to other Spectrum modules </li></ul><ul><ul><li>AIM for AIDS </li></ul></ul><ul><ul><li>FamPlan for Family Planning </li></ul></ul><ul><li>Cohort-based model </li></ul><ul><ul><li>Children cannot die multiple times </li></ul></ul><ul><ul><li>Impacts can be lagged to a later age period </li></ul></ul><ul><ul><li>Risk factors affect probability of mortality </li></ul></ul>
  5. 5. 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 <ul><li>Deaths averted </li></ul><ul><li>By cause </li></ul><ul><li>By intervention </li></ul>Intervention Impact C1 C2 C3 C4 … Int1   Int2  Int3   <ul><li>Intervention Coverage </li></ul><ul><li>Current (database) </li></ul><ul><li>Future (user-defined) </li></ul><ul><li>Health Status </li></ul><ul><li>% stunted </li></ul><ul><li>Malaria prevalence </li></ul><ul><li>Vit A deficiency </li></ul><ul><li>Zinc deficiency </li></ul><ul><li>WHO Database </li></ul>Stunting
  6. 6. Interventions Included <ul><li>Proximal factors </li></ul><ul><ul><li>Not distal (i.e. poverty, lack of education) </li></ul></ul><ul><li>Work through health programs </li></ul><ul><ul><li>Not included: income, education and crowding, etc. </li></ul></ul><ul><ul><li>Sanitation is the exception </li></ul></ul><ul><li>Feasible in a low income country </li></ul><ul><ul><li>68 priority countries with highest MNCH mortality </li></ul></ul><ul><li>Cause-specific evidence of effect </li></ul><ul><ul><li>Research studies or systematic reviews </li></ul></ul><ul><ul><li>Delphi method if research is impossible (i.e. CEmOC) </li></ul></ul><ul><ul><li>Updated every year </li></ul></ul>
  7. 7. Types of Interventions <ul><ul><li>Maternal, neonatal, child </li></ul></ul><ul><ul><li>Periconceptual, antenatal, birth, immediate postnatal, child </li></ul></ul><ul><ul><li>Preventive, curative </li></ul></ul><ul><ul><li>Nutritional, vaccination, water/sanitation, treatment </li></ul></ul><ul><ul><li>Risk factors: Cause-of-death specific </li></ul></ul><ul><ul><li>Immediate, time-lagged </li></ul></ul><ul><ul><li>External (family planning, AIDS), internal (all others) </li></ul></ul>
  8. 8. Peri-conceptual Interventions <ul><li>(Family planning (birth spacing)) </li></ul><ul><li>Folic acid supplementation or fortification </li></ul><ul><li>Abortion services </li></ul>Antenatal Interventions <ul><li>Syphilis detection </li></ul><ul><li>Calcium supplementation </li></ul><ul><li>Multiple micronutrient supplementation </li></ul><ul><li>IPTp malaria (or ITN use) </li></ul><ul><li>Tetanus toxoid </li></ul><ul><li>Balanced energy supplementation </li></ul><ul><li>Case management of maternal malaria </li></ul>
  9. 9. Care/Interventions During Child Birth <ul><li>Antenatal corticosteroids for preterm labor </li></ul><ul><li>Antibiotics for pPRoM </li></ul><ul><li>Essential care for all women and immediate ENC (institutional)* </li></ul><ul><li>Basic emergency obstetric care* </li></ul><ul><li>Comprehensive emergency obstetric care* </li></ul><ul><li>Active management of the 3rd stage of labor - AMTSL </li></ul><ul><li>Newborn resuscitation (institutional & home) </li></ul><ul><li>Clean practices and immediate ENC (home) </li></ul>
  10. 10. Preventive Interventions <ul><li>Kangaroo mother care </li></ul><ul><li>Routine postnatal care (healthy practices & illness detection) </li></ul><ul><li>Breastfeeding promotion </li></ul><ul><li>Complementary feeding </li></ul><ul><ul><li>Education only </li></ul></ul><ul><ul><li>Education and supplementation </li></ul></ul><ul><li>Insecticide treated materials </li></ul><ul><li>Vitamin A for prevention </li></ul><ul><li>Zinc for prevention </li></ul><ul><li>Improved water source within 30 minutes </li></ul><ul><li>Water connection in the home </li></ul><ul><li>Improved excreta disposal (latrine, toilet) </li></ul><ul><li>Hand washing with soap </li></ul><ul><li>Hygienic disposal of children’s stools </li></ul><ul><li>Rotavirus vaccine </li></ul><ul><li>Measles vaccine </li></ul><ul><li>Hib vaccine </li></ul><ul><li>Pneumococcal vaccine </li></ul><ul><li>DPT3 vaccine </li></ul><ul><li>Polio vaccine </li></ul><ul><li>BCG vaccine </li></ul>
  11. 11. Curative Interventions <ul><li>Case management of serious neonatal illnesses </li></ul><ul><ul><li>Oral antibiotics </li></ul></ul><ul><ul><li>Injectable antibiotics </li></ul></ul><ul><ul><li>Full supportive care: oxygen, IV fluids, IV antibiotics) </li></ul></ul><ul><li>ORS for diarrhea </li></ul><ul><li>Antibiotics for dysentery </li></ul><ul><li>Zinc for treatment of diarrhea </li></ul><ul><li>Case management of pneumonia </li></ul><ul><li>Vitamin A for measles treatment </li></ul><ul><li>Therapeutic feeding </li></ul><ul><li>Antimalarials </li></ul><ul><li>(Cotrimoxazole for HIV) </li></ul><ul><li>(ART for children) </li></ul>
  12. 12. NOT Included in the Model <ul><li>Education </li></ul><ul><li>Motivation </li></ul><ul><li>Gender issues </li></ul><ul><li>Economic status </li></ul><ul><li>Emergencies (i.e. famine, flooding) </li></ul><ul><li>Delivery mechanism </li></ul><ul><ul><li>Only as relates to total population coverage </li></ul></ul><ul><li>Quality of care </li></ul><ul><ul><li>Can somewhat take this into account </li></ul></ul>Assumption: Several of these factors are DISTAL factors which MAY work through COVERAGE changes…thus MAY already be in the model
  13. 13. Interventions NOT in LiST <ul><li>Magnesium sulfate </li></ul><ul><li>De-worming </li></ul><ul><li>IPTi </li></ul><ul><li>Breastfeeding initiation within 1 hour </li></ul><ul><li>Birth spacing benefit </li></ul><ul><li>Treatment of water in the home </li></ul><ul><li>Iron (or iron-folate) supplementation </li></ul>
  14. 14. Data Needed to Run LiST <ul><li>Country-Specific </li></ul><ul><ul><li>Population data and trends </li></ul></ul><ul><ul><ul><li>Default: UN Population Division 1950-2050 (DemProj) </li></ul></ul></ul><ul><ul><ul><li>User entered (district) data </li></ul></ul></ul><ul><ul><li>Cause of death structure </li></ul></ul><ul><ul><ul><li>Default: WHO/UNICEF (2000-2003) </li></ul></ul></ul><ul><ul><ul><li>User entered data </li></ul></ul></ul><ul><ul><li>Intervention coverage </li></ul></ul><ul><ul><ul><li>Population based data </li></ul></ul></ul><ul><ul><ul><li>Default: Childinfo.org or DHS/MICS (closest to 2003) </li></ul></ul></ul><ul><ul><ul><li>User entered data </li></ul></ul></ul><ul><li>Global </li></ul><ul><ul><li>Intervention Efficacies </li></ul></ul><ul><ul><ul><li>User entered data </li></ul></ul></ul>
  15. 15. Building Blocks of the Model <ul><li>Preventions </li></ul><ul><li>Treatments </li></ul><ul><li>Risk factors </li></ul><ul><li>Using Multiple interventions </li></ul><ul><ul><li>Two Preventions (or Risk Factors): </li></ul></ul><ul><ul><ul><li>Proportional impact by coverage/effect size </li></ul></ul></ul><ul><ul><ul><ul><li>Calculated on residual deaths </li></ul></ul></ul></ul><ul><ul><ul><li>No double counting </li></ul></ul></ul><ul><ul><li>Preventions and Treatments: </li></ul></ul><ul><ul><ul><li>Enter prevention(s), then treatment(s) </li></ul></ul></ul><ul><ul><ul><li>Deaths not already averted </li></ul></ul></ul>
  16. 16. Age Groups <ul><li>Neonatal </li></ul><ul><ul><li>< 1 month </li></ul></ul><ul><li>Post-neonatal </li></ul><ul><ul><li>1-5 months </li></ul></ul><ul><ul><li>6-11 months </li></ul></ul><ul><ul><li>12-23 months </li></ul></ul><ul><ul><li>24-59 months </li></ul></ul>
  17. 17. Multiple Interventions in LiST <ul><li>In the context of other interventions </li></ul><ul><li>In the context of the baseline health status </li></ul><ul><li>In the context of changes over time </li></ul><ul><li>You create your own package!!! </li></ul>
  18. 18. Odds and Ends <ul><li>Effect sizes do not vary on based on either coverage of disease prevalance </li></ul><ul><ul><li>Exception: *Herd Immunity* </li></ul></ul><ul><li>Some components are grouped </li></ul><ul><li>Multiple nutrition impacts </li></ul>
  19. 19. Groupings <ul><li>Antenatal Care </li></ul><ul><ul><li>Components </li></ul></ul><ul><ul><ul><li>Case management, syphilis </li></ul></ul></ul><ul><li>Child Birth Care </li></ul><ul><ul><li>Facility and Home based deliveries </li></ul></ul><ul><ul><li>Components </li></ul></ul><ul><ul><ul><li>Corticosteroids, antibiotics, labor monitoring/ emergency obstetric care, resuscitation, clean delivery </li></ul></ul></ul><ul><li>Water </li></ul><ul><ul><li>Components </li></ul></ul><ul><ul><ul><li>Water within 30 minutes, water in the home </li></ul></ul></ul>
  20. 20. Nutrition Impacts <ul><li>Direct impact </li></ul><ul><ul><li>Therapeutic feeding </li></ul></ul><ul><ul><li>Balanced energy supplementation </li></ul></ul><ul><ul><li>Multiple micronutrient supplementation </li></ul></ul><ul><ul><li>Complementary feeding (education ± supplementation) </li></ul></ul><ul><ul><li>Breast feeding prevalence/promotion </li></ul></ul><ul><ul><li>Zinc supplementation </li></ul></ul><ul><ul><li>Water and sanitation </li></ul></ul><ul><li>Indirect impact </li></ul><ul><ul><li>Water and sanitation – via diarrhea </li></ul></ul><ul><ul><li>IPTp – on IUGR </li></ul></ul><ul><ul><li>Zinc – via diarrhea </li></ul></ul><ul><li>None </li></ul><ul><ul><li>Vitamin A supplementation </li></ul></ul>
  21. 21. Stunting Zinc Diarrhea incidence IUGR Appropriate Complementary Feeding Complementary feeding education and/or supplementation Previous Stunting
  22. 22. Malaria Mortality Disease Specific Treatments Disease Specific Preventions Risk factors ITN/IRS Antimalarials Stunting
  23. 23. 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
  24. 24. Advanced Topics FamPlan and AIM in LiST <ul><li>LiST can be linked to AIM (HIV) and FamPlan (Family Planning) Spectrum modules </li></ul><ul><li>To examine combined, estimated, impact multiple models must be compared. </li></ul><ul><li>Please contact a LiST trainer to assist with any LiST, FamPlan, or AIM integration </li></ul>
  25. 25. What LiST Is, What LiST Isn’t <ul><li>Is </li></ul><ul><li>Multi-cause mortality model </li></ul><ul><li>Mathematic model </li></ul><ul><li>Models coverage impacts </li></ul><ul><li>Potential impact assessment </li></ul><ul><li>National or sub-national planning tool </li></ul><ul><li>Discussion points </li></ul><ul><li>Evidence-based </li></ul><ul><li>Isn’t </li></ul><ul><li>Natural history model </li></ul><ul><li>Truth </li></ul><ul><li>Probabilistic model </li></ul><ul><li>Detailed costing or planning tool </li></ul><ul><li>Bottlenecks, budgeting </li></ul><ul><li>Exhaustive </li></ul>
  26. 26. Projection of Additional Lives Saved <ul><li>Projections of additional lives saved are based on the assumption that all other coverage levels remain the same!!! </li></ul><ul><li>This is important to keep in mind for mature interventions (i.e. Immunization) </li></ul><ul><li>We do not want projections to inadvertently make the case for decreasing funding/coverage for these interventions </li></ul>
  27. 27. Some Limitations <ul><li>Data availability </li></ul><ul><ul><li>If no baseline, can’t evaluate impact accurately </li></ul></ul><ul><li>Data quality </li></ul><ul><li>Sensible scale up targets </li></ul><ul><ul><li>Feasible, acceptable, funds available </li></ul></ul><ul><ul><li>EX: Project presented to MOH a plan to scale up handwashing from 3% to 80% </li></ul></ul><ul><li>Interventions included in software </li></ul>
  28. 28. Some Limitations: Maternal Health Intervention Assumptions <ul><li>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 </li></ul><ul><li>MH interventions included in LiST are packages that are only effective in reducing mortality if all services are provided at quality </li></ul>
  29. 29. LiST Validation <ul><li>“ How do you know that this works?” </li></ul><ul><li>“ How can it be used in reality?” </li></ul>
  30. 30. Neonatal Package Modeling <ul><li>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 </li></ul>
  31. 31. ACSD Countries <ul><li>Ghana (1% underestimate) - Good </li></ul><ul><li>Mali (10% underestimate) – OK </li></ul><ul><li>Predominantly post-neonatal interventions </li></ul><ul><li>Data from DHS and other sources </li></ul><ul><li>Adequate correlation </li></ul>
  32. 32. Modeling Mortality Rates and Equity
  33. 33. How Can LiST be Used? <ul><li>Planning, Evaluation, Advocacy </li></ul><ul><li>Strategic planning </li></ul><ul><ul><li>Which interventions are necessary to reduce mortality? (maternal, neonatal, under-5) </li></ul></ul><ul><ul><li>By how much will project targets reduce mortality? </li></ul></ul><ul><li>Evaluation and intermediate-term follow-up </li></ul><ul><ul><li>What is the impact of observed coverage changes? </li></ul></ul><ul><ul><li>Evaluation of historic trends (i.e. multiple DHS/MICS/KPC surveys) </li></ul></ul><ul><li>Predict estimated lives saved (past and future) </li></ul><ul><ul><li>How many lives were saved, total and by intervention, over the course of your project (in your project area)? </li></ul></ul><ul><ul><li>How many deaths remain after intervention scale ups? </li></ul></ul>
  34. 34. How Has LiST Been Used? <ul><li>Globally </li></ul><ul><ul><li>Global Action Plan for Pneumonia </li></ul></ul><ul><ul><li>‘ Impatient Optimist’ speech by Bill Gates </li></ul></ul><ul><li>Regionally </li></ul><ul><ul><li>ASADI, by Saving Newborn Lives </li></ul></ul><ul><li>Country level </li></ul><ul><ul><li>Catalytic initiative: to guide planning and priority setting </li></ul></ul><ul><ul><ul><li>Malawi, Ghana </li></ul></ul></ul><ul><li>Sub-National </li></ul><ul><ul><li>Lives Saved by CSHGP projects </li></ul></ul>
  35. 35. Who Uses LiST ? <ul><li>United Nations </li></ul><ul><ul><li>WHO/CAH </li></ul></ul><ul><ul><li>UNICEF-ESARO </li></ul></ul><ul><li>Development Partners </li></ul><ul><ul><li>USAID </li></ul></ul><ul><ul><li>BMGF </li></ul></ul><ul><ul><li>CIFF </li></ul></ul><ul><ul><li>CIDA </li></ul></ul><ul><ul><li>Save the Children </li></ul></ul><ul><ul><li>MCHIP partners </li></ul></ul><ul><ul><li>PMI </li></ul></ul><ul><ul><li>JSI </li></ul></ul><ul><li>Other organizations </li></ul><ul><ul><li>Abt </li></ul></ul><ul><ul><li>JHSPH </li></ul></ul><ul><ul><li>ICF Macro </li></ul></ul><ul><li>Countries </li></ul><ul><ul><li>Catalytic Initiative </li></ul></ul><ul><ul><ul><li>Malawi </li></ul></ul></ul><ul><ul><ul><li>Burkina Faso </li></ul></ul></ul><ul><ul><ul><li>Ghana </li></ul></ul></ul><ul><ul><li>Doris Duke Foundation </li></ul></ul>
  36. 36. Future Directions for LiST <ul><li>Add the new CHERG Cause of Death structure - 2008 </li></ul><ul><li>Birth spacing benefit of family planning </li></ul><ul><li>Additional costing tie-ins </li></ul><ul><ul><li>Finalization of CHOICE based costing tool </li></ul></ul><ul><ul><li>Links to the fiscal and bottleneck portions of MBB </li></ul></ul><ul><li>Updated interventions – continuous </li></ul><ul><ul><li>Research, Reviews, Model updated </li></ul></ul><ul><ul><li>Documentation – to be published in the winter </li></ul></ul><ul><li>‘ Research’ version </li></ul><ul><ul><li>To predict the impact of future developments </li></ul></ul>
  37. 37. Who Owns LiST ? <ul><li>WHO? </li></ul><ul><li>UNICEF? </li></ul><ul><li>US Fund for UNICEF? </li></ul><ul><li>CHERG? </li></ul><ul><li>Gates Foundation? </li></ul><ul><li>Futures Institute? </li></ul><ul><li>JHSPH? </li></ul>INDEPENDENT
  38. 38. LiST Contributors Institute for International Programs
  39. 39. How to Get LiST <ul><li>FREE </li></ul><ul><ul><li>www.futuresinstitute.org </li></ul></ul><ul><ul><li>www.healthpolicyinitiative.com/index.cfm?id=software&get=Spectrum </li></ul></ul><ul><ul><li>www.jhsph.edu/iip </li></ul></ul><ul><li>Languages </li></ul><ul><ul><li>English, French, Spanish, Portuguese </li></ul></ul><ul><li>Manuals </li></ul><ul><ul><li>English, French, Spanish, Portuguese </li></ul></ul><ul><li>Contact </li></ul><ul><ul><li>Ingrid Friberg - ifriberg@jhsph.edu </li></ul></ul>

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