Review the Effectiveness of Community-based Primary Health Care in Improving Child and Maternal Health: Leveraging Results for Advocacy HENRY PERRY and PAUL FREEMAN

1. Review of the Effectiveness of
CBPHC in Improving Maternal,
Neonatal and Child Health
Henry Perry and Paul Freeman
CORE Group Spring Meeting
19 May 2016

2. Outline
• Introduction and methods – Henry Perry
• Findings – Paul Freeman
• Broader implications – Henry Perry

3. Background
• Over the past 3 decades, growing recognition of
importance of community-based approaches to health
improvement of children
• CBPHC Working Group at APHA: Henry Perry and Paul
Freeman
• First efforts to locate funding: proposals to Gates
Foundation and Rockefeller Foundation (2004) - declined
• Small grant ($10,000) obtained from WHO in 2005, which
provided impetus for forming Expert Panel and
formalizing the review process
• Initial goal to review only studies which had assessed
mortality impact

4. Study protocol
• Developed jointly by our Study Directors (Henry
Perry and Paul Freeman) and Study Coordinators
(Bahie Rassekh and Sundeep Gupta) with an
Expert Panel (chaired by Carl Taylor)
• Formation of Expert Panel to guide study protocol
• Protocol expanded beyond mortality impact to
other health outcomes and equity

5. Study protocol (cont.)
• Any document (peer-reviewed or not) assessing
the impact of one or more CBPHC interventions on
child health (coverage of a key child survival
indicator, nutritional status, serious morbidity or
mortality) among children in a geographically
defined population
• Two separate reviews, one consolidated summative
review
• Data transfered to electronic database for analysis

6. Selected research questions
• How strong is the evidence ?
• What are the specific CBPHC activities that effective?
• What conditions facilitate the effectiveness and what
community-based approaches appear to be most
effective?
• What characteristics do effective CBPHC activities share?
• How strong is the evidence that partnerships between
communities and health systems are required in order to
improve child and maternal health?
• How strong is the evidence that CBPHC can promote
equity?

7. Progress made
• Strong cooperation from the American Public
Health Association
• Small grants from UNICEF, World Bank and USAID
(2008-2013)
• Availability of Henry Perry’s time to devote to this
effort through his endowed position at Future
Generations (2007 and 2008)
• 2015 – Small grant from Bill and Melinda Gates
Foundation to update the review through the end of
2015 and include maternal health

8. Written Products Produced
http://www.coregroup.org/storage/documents/finalcbphcreport_july2009.pdf

9. 2009

10. http://www.mchip.net/sites/default/files/USAID%20CBPHC%20FINAL.pdf
2011

11. Contributors
• More than 150 people contributed as
reviewers, many of them volunteers
• A special thanks to many students at Johns
Hopkins who worked on this, especially:
– Emma Sacks (now at MCSP)
– Meike Schleiff
– Mary Carol Jennings
– Richard Kumapley (now at UNICEF)

12. Our study team and the
CBPHC Review!

13. Vietnamese proverb:
When riding on the back of a tiger
don’t let go!

14. Articles screened
• 4,276 articles screened on child health
• 7,890 articles screened on maternal health
• 549 articles on child health included in review
• 153 articles on maternal health included
• 702 articles total

15. Key findings

16. Maternal health
Findings 153 studies -3 categories of outcomes
• Reduction of medical complications of pregnancy (37.2%)
• Provision of routine maternity care (57.1%)
• Development of community capacity to promote
maternal health and refer obstetric emergencies (6%)
Outcome indicators
• Maternal mortality ratio
• Maternal morbidity
• Coverage of maternal health services

17. Community-based interventions with a
measurable effect on maternal health
• Maternal tetanus immunization in antenatal
• Intermittent preventive treatment of malaria
• Misoprostol during third stage of labor
• Immediate post partum breastfeeding promotion
Key Community-based Strategies
• Participatory women’s groups
• Home visits – antenatal and postnatal
• Strengthening connection health facility - community

18. Neonatal health
Sepsis is a major cause of neonatal mortality and can be effectively
addressed by community-based programs
Effective community-based interventions
• Oral antibiotics for newborn infection
• Clean post-natal practices
• Thermal care
• Chlorhexidene application to the umbilical cord
• Micronutrient supplementation (during pregnancy)
• Folic acid supplementation (during pregnancy)
• Exclusive breastfeeding
• Balanced energy supplementation (during pregnancy)
• Labor and delivery management

19. Home-based neonatal care
• Management of birth asphyxia
• Promotion of immediate and exclusive
breastfeeding
• Promotion of cleanliness
• Application of topical antiseptic to the
umbilical cord
• Prevention of hypothermia
• Diagnosis and treatment of neonatal sepsis by
Community Health Workers

20. Child health
All major causes of death in children 1-59 months age can be
effectively addressed by well-trained and supported CHWs
Effective community-based interventions
• Immunizations (BCG, polio, diphtheria, pertussis, tetanus, measles,
Haemophilus influenza type b, pneumococcus, rotavirus )
• Vitamin A to all children 6-59 months of age
• Zinc to all children 6-59 months of age
• Promotion of exclusive BF first 6 months, continued BF after 6 mn
• Promotion of complementary feeding beginning at 6 months of age
• Rehabilitation of children with protein-calorie undernutrition
(including severe acute undernutrition per ready-to-use dry
therapeutic foods)

21. Community-based interventions with a
measurable impact on child health
• Promotion of hygiene (including handwashing), safe
water, and sanitation
• CB treatment of diarrhea with ORT and zinc
• CB treatment of childhood pneumonia
• ITNs in malaria-endemic areas
• Indoor residual spraying in malaria-endemic areas
• Community-based treatment of malaria – IPTi & acute
infection using RDT in malaria-endemic areas
• Integrated Community Case Management of Childhood
Illness, or iCCM
• Iodine supplementation in iodine-deficient areas

22. Key community-based strategies
identified for child health
• Home visitation by CHWs for education and
early treatment/referral of children
• Community-based treatment by CHWs for
pneumonia, diarrhea, malaria and acute
malnutrition (iCCM)
• Outreach from health facilities, especially to
support immunization and CHWs
• Participatory women’s groups (Care Groups
especially)

23. Equity
• 52 assessments in 43 studies of the impact of
CBPHC on equity (SES/ wealth)
• 86.5% - a pro-equity effect (impact on health
more favorable in the disadvantaged)
• 5.8% - equitable effect- impact in the
disadvantage group & advantaged equal
• 7.8% - demonstrated an inequitable effect

24. Equity effects
• CBPHC approaches can reduce inequities in terms of
population coverage, morbidity, nutritional status and
mortality
• Programs that reach every household are effective in
achieving equity
• The effects of CBPHC programs on promoting gender equity
are not well-studied
• Equity is not easy to study because it requires larger samples
sizes in order to be able to estimate program effects in
subgroups

25. Strategies
• Community collaborations
• Intervention delivery
• Health systems strengthening

26. Strategies (cont.)

27. Broader implications

28. Deaths averted by health-care packages
through three service platforms
9 April 2016

29. https://openknowledge.worldbank.org/bitstream/handle/10986/23833
/9781464803482.pdf?sequence=3&isAllowed=y.

31. Strengths of our review
• Emphasis on:
– How interventions are implemented
– Forms of community collaboration
– Findings from integrated programs
– Quality and forms of evidence currently available
– Limitations of current evidence
– Endorsement of importance of our findings by a
world-class Expert Panel

32. Policy and advocacy messages
• Communities are an undervalued resource
• CBPHC should be a priority for government
funding for health improvement
• Community-based family planning and local
birthing centers will bring strength and
effectiveness to CBPHC
• A strong CBPHC service delivery platform is
essential not only for RMNCH but also for HIV,
TB, malaria, chronic diseases, and surveillance

33. Policy and advocacy messages
(cont.)
• The science and practice of CBPHC (the
development and implementation of
community-based programs for improving the
health of geographically defined populations)
is today where the science and practice of
medicine (the care of individual patients by
doctors) was a century ago
• Just as for medical practice a century ago,
CBPHC today is at the dawn of a new era of
great promise for humankind

34. Questions for table discussions
• What key messages do you find most exciting
for “making the case” for your work?
• How could you use these results as part of
your own organization’s branding and
communications with donors (pointing to the
effectiveness and impact of your work)?
• How could we collectively use these results for
donor education, fundraising, and advocacy?
• What could CORE do to help with this?