David R. Marsh

Research Priorities for the Reduction of Perinatal and Neonatal Morbidity and Mortality in Developing Country Communities

Although post-neonatal and child mortality rates have declined dramatically in many developing countries in recent decades, neonatal mortality rates have remained relatively unchanged. Neonatal mortality now accounts for approximately two-thirds of the 8 million deaths in children less than 1 year of age, and nearly four-tenths of all deaths in children less than 5 years of age. Worldwide, 98% of all neonatal deaths occur in developing countries, mostly at home, and largely attributable to infections, birth asphyxia and injuries, and consequences of prematurity, low birth weight and congenital anomalies. We review principal determinants of neonatal morbidity and mortality during the antenatal, intrapartum and postpartum periods, and propose priority community-based research activities to develop, test and adapt inexpensive, practical and sustainable interventions during these periods to reduce perinatal and neonatal morbidity and mortality in developing countries.

World Health Organization/United Nations Children's Fund Joint Statement on Integrated Community Case Management: An Equity-Focused Strategy to Improve Access to Essential Treatment Services for Children

This statement presents the latest evidence for integrated community case management of childhood illness, describes the necessary program elements and support tools for effective implementation, and lays out actions that countries and partners can take to support the implementation of integrated community case management at scale.

Community case management of pneumonia: at a tipping point?

Pneumonia is the leading cause of child mortality globally. Community case management (CCM) of pneumonia by community health workers is a feasible, effective strategy to complement facility-based management for areas that lack access to facilities. We surveyed experts in the 57 African and Asian countries with the highest levels and rates of childhood mortality to assess current policies, implementation and plans regarding CCM of pneumonia. About one-third (20/54) of countries reported policies supporting CCM for pneumonia, and another third (18/54) reported no policy against the strategy. Half (27/54) the countries reported some implementation of CCM for pneumonia, but often on a small scale. A few countries sustain a large-scale programme. Programmes, community health workers and policy parameters varied greatly among implementing countries. About half (12/26) of non-implementing countries are planning to move ahead with the strategy. Momentum is gathering for CCM for pneumonia as a strategy to address the pneumonia treatment gap and help achieve Millennium Development Goal 4. Challenges remain to: (1) introduce this strategy into policy and implement it in high pneumonia burden countries; (2) increase coverage of this strategy in countries currently implementing it; and (3) better define and monitor implementation at the country level.

Advancing newborn health and survival in developing countries: a conceptual framework.

Four million newborns die every year at home, often without skilled care at delivery or any other contact with the formal health system. Improved household practices and use of services, often in the community, should improve survival. We developed a conceptual framework for household and community newborn and maternal care that acknowledges the inseparability of the mother and neonate, yet stresses elements relating to the newborn, heretofore underemphasized in safe motherhood and child-survival programs. The framework identifies five paths that, if implemented well, would generally improve newborn outcomes: (1) use of routine maternal and newborn care and good-quality services; (2) response to maternal danger signs; (3) response to the nonbreathing newborn; (4) care for the low birth weight baby; and (5) response to newborn danger signs, particularly those of infection. This model, balancing preventive (19 routine behaviors) and curative care (14 special behaviors), is rooted in the community, bridges safe motherhood and child survival, and provides a framework for newborn health research, programmatic, and advocacy agendas for developing countries.

Introduction to a Special Supplement: Evidence for the Implementation, Effects, and Impact of the Integrated Community Case Management Strategy to Treat Childhood Infection

Introduction to a Special Supplement : Evidence for the Implementation, Effects, and Impact of the Integrated Community Case Management Strategy to Treat Childhood Infection

Community Case Management of Childhood Illness in Nicaragua: Transforming Health Systems in Underserved Rural Areas

While social factors broadly determine health outcomes, strategic health workforce innovations such as community case management (CCM) can redress social inequalities in access to health care. Community case management enables trained health workers to assess children, diagnose common childhood infections, administer medicines, and monitor life-saving treatment in the poor, remote communities where they reside. This article reports on research that combined focus group discussions and key informant interviews to examine the perceptions of multiple stakeholders, with monitoring data, in order to assess programmatic results, limitations, and lessons learned in implementing CCM in Nicaragua. We found that CCM increases the use of curative services by poor children with pneumonia, diarrhea, or dysentery by five to six-fold over facility-based services. Apart from dramatically increasing geographic access to treatment for underserved groups, our qualitative research suggests that Nicaragua’s CCM model also addresses the managerial challenges and social relations that underpin good quality of care, care-giver knowledge and awareness, and community mobilization, all health system-strengthening factors that are central to equitably and effectively improving child health. While our findings are promising, we suggest areas for further operational research to strengthen CCM program learning and functioning.

The effect of providing fansidar (sulfadoxine-pyrimethamine) in schools on mortality in school-age children in Malawi

Malaria is a major cause of death in school-age (5-18 years) children in Malawi. Save the Children Federation helped schools in Mangochi District, Malawi, to obtain pupil-treatment kits, which enabled teachers to dispense sulfadoxine-pyrimethamine tablets according to national guidelines. The overall and malaria-specific mortality rates were calculated for the 3 years before and 2 years after the intervention was introduced; rates dropped from 2.2 to 1.44 deaths/1000 student-years and from 1.28 to 0.44 deaths/1000 student-years, respectively. School-based interventions could play a part in mitigating malaria.

Setting global research priorities for integrated community case management (iCCM): Results from a CHNRI (Child Health and Nutrition Research Initiative) exercise.

Aims To systematically identify global research gaps and resource priorities for integrated community case management (iCCM). Methods An iCCM Child Health and Nutrition Research Initiative (CHNRI) Advisory Group, in collaboration with the Community Case Management Operational Research Group (CCM ORG) identified experts to participate in a CHNRI research priority setting exercise. These experts generated and systematically ranked research questions for iCCM. Research questions were ranked using a “Research Priority Score” (RPS) and the “Average Expert Agreement” (AEA) was calculated for every question. Our groups of experts were comprised of both individuals working in Ministries of Health or Non Governmental Organizations (NGOs) in low– and middle–income countries (LMICs) and individuals working in high–income countries (HICs) in academia or NGO headquarters. A Spearman’s Rho was calculated to determine the correlation between the two groups’ research questions’ ranks. Results The overall RPS ranged from 64.58 to 89.31, with a median score of 81.43. AEA scores ranged from 0.54 to 0.86. Research questions involving increasing the uptake of iCCM services, research questions concerning the motivation, retention, training and supervision of Community Health Workers (CHWs) and concerning adding additional responsibilities including counselling for infant and young child feeding (IYCF) and treatment of severe acute malnutrition (SAM) ranked highly. There was weak to moderate, statistically significant, correlation between scores by representatives of high–income countries and those working in–country or regionally (Spearman’s ρ = 0.35034, P < 0.01). Conclusions Operational research to determine optimal training, supervision and modes of motivation and retention for the CHW is vital for improving iCCM, globally, as is research to motivate caregivers to take advantage of iCCM services. Experts working in–country or regionally in LMICs prioritized different research questions than those working in organization headquarters in HICs. Further exploration is needed to determine the nature of this divergence.

Benchmarks to measure readiness to integrate and scale up newborn survival interventions

Neonatal mortality accounts for 40% of under-five child mortality. Evidence-based interventions exist, but attention to implementation is recent. Nationally representative coverage data for these neonatal interventions are limited; therefore proximal measures of progress toward scale would be valuable for tracking change among countries and over time. We describe the process of selecting a set of benchmarks to assess scale up readiness or the degree to which health systems and national programmes are prepared to deliver interventions for newborn survival. A prioritization and consensus-building process was co-ordinated by the Saving Newborn Lives programme of Save the Children, resulting in selection of 27 benchmarks. These benchmarks are categorized into agenda setting (e.g. having a national newborn survival needs assessment); policy formulation (e.g. the national essential drugs list includes injectable antibiotics at primary care level); and policy implementation (e.g. standards for care of sick newborns exist at district hospital level). Benchmark data were collected by in-country stakeholders teams who filled out a standard form and provided evidence to support each benchmark achieved. Results are presented for nine countries at three time points: 2000, 2005 and 2010. By 2010, substantial improvement was documented in all selected countries, with three countries achieving over 75% of the benchmarks and an additional five countries achieving over 50% of the benchmarks. Progress on benchmark achievement was accelerated after 2005. The policy process was similar in all countries, but did not proceed in a linear fashion. These benchmarks are a novel method to assess readiness to scale up, an important construct along the pathway to scale for newborn care. Similar exercises may also be applicable to other global health issues.

Community case management in Nicaragua: lessons in fostering adoption and expanding implementation

Community case management (CCM) as applied to child survival is a strategy that enables trained community health workers or volunteers to assess, classify, treat and refer sick children who reside beyond the reach of fixed health facilities. The Nicaraguan Ministry of Health (MOH) and Save the Children trained and supported brigadistas (community health volunteers) in CCM to improve equitable access to treatment for pneumonia, diarrhoea and dysentery for children in remote areas. In this article, we examine the policy landscape and processes that influenced the adoption and implementation of CCM in Nicaragua. Contextual factors in the policy landscape that facilitated CCM included an international technical consensus supporting the strategy; the role of government in health care provision and commitment to reaching the poor; a history of community participation; the existence of community-based child survival strategies; the decentralization of implementation authority; internal MOH champions; and a credible catalyst organization. Challenges included scepticism about community-level cadres; resistance from health personnel; operational gaps in treatment norms and materials to support the strategy; resource constraints affecting service delivery; tensions around decentralization; and changes in administration. In order to capitalize on the opportunities and overcome the challenges that characterized the policy landscape, stakeholders pursued various efforts to support CCM including sparking interest, framing issues, monitoring and communicating results, ensuring support and cohesion among health personnel, supporting local adaptation, assuring credibility and ownership, joint problem solving, addressing sustainability and fostering learning. While delineated as separate efforts, these policy and implementation processes were dynamic and interactive in nature, balancing various tensions. Our qualitative analysis highlights the importance of supporting routine monitoring and documentation of these strategic operational policy and management issues vital for CCM success. We also demonstrate that while challenges to CCM adoption and implementation exist, they are not insurmountable.