Nicholas P. Oliphant

Fluctuations in Wasting in Vulnerable Child Populations in the Greater Horn of Africa

Background Malnutrition in preschool children, usually measured as wasting, is widely used to assess possible needs for emergency humanitarian interventions in areas vulnerable to drought, displacement, and related causes of food insecurity. The extent of fluctuations in wasting by season, year-to-year, and differential effects by livelihood group, need to be better established as a basis for interpretation together with ways of presenting large numbers of survey results to facilitate interpretation. Objective To estimate levels of and fluctuations in wasting prevalences in children from surveys conducted in arid and semiarid areas of the Greater Horn of Africa according to livelihood (pastoral, agricultural, mixed, migrant), season or month, and year from 2000 to 2006. Methods Results from around 900 area-level nutrition surveys (typical sample size, about 900 children) were compiled and analyzed. These surveys were carried out largely by nongovernmental organizations, coordinated by UNICEF, in vulnerable areas of Eritrea, Ethiopia, Kenya, Somalia, Southern Sudan, and Uganda. Demographic and Health Survey (DHS) and Multiple Indicator Cluster Survey (MICS) data were used for comparison. Data were taken from measurements of children 0 to 5 years of age (or less than 110 cm in height). Results Among pastoral child populations, the average prevalence of wasting (< −2 SD weight-for-height) was about 17%, 6–7 percentage points higher than the rates among agricultural populations or populations with mixed livelihoods. Fluctuations in wasting were greater among pastoralists during years of drought, with prevalences rising to 25% or higher; prevalences among agricultural populations seldom exceeded 15%. This difference may be related to very different growth patterns (assessed from DHS and UNICEF/MICS surveys), whereby pastoral children typically grow up thinner but taller than children of agriculturalists. Wasting peaks are seen in the first half of the year, usually during the dry or hunger season. In average years, the seasonal increase is about 5 percentage points. Internally displaced people and urban migrants have somewhat higher prevalence rates of wasting. Year-to-year differences are the largest, loosely correlated with drought at the national level but subject to local variations. Conclusions Tracking changes in wasting prevalence over time at the area level—e.g., with time-series graphical presentations—facilitates interpretation of survey results obtained at any given time. Roughly, wasting prevalences exceeding 25% in pastoralists and 15% in agriculturalists (taking account of timing) indicate unusual malnutrition levels. Different populations should be judged by population-specific criteria, and invariant prevalence cutoff points avoided; interpretation rules are suggested. Survey estimates of wasting, when seen in the context of historical values and viewed as specific to different livelihood groups, can provide useful timely warning of the need for intervention to mitigate developing nutritional crises.

The contribution of child health days to improving coverage of periodic interventions in six African countries.

Background Child Health Days have been implemented since the early 2000s in a number of sub-Saharan African countries with support from UNICEF and other development partners with the aim to reduce child morbidity and mortality. Objective To estimate the effect of Child Health Days on preventive public health intervention coverage, and possible trade-offs of Child Health Days with facility-based health systems coverage, in sub-Saharan Africa. Methods Data were assembled and analyzed from population-based sample surveys and administrative records and from local government sources, from six countries. Field observations (published elsewhere) provided context. Results Child Health Days contributed to improving measles immunization coverage by about 10 percentage points and, importantly, provided an opportunity for a second dose. Child Health Days achieved high coverage of vitamin A supplementation and deworming, and improved access to insecticide-treated nets. Reported measles cases declined to near zero by 2003–5—a result of the combined efforts of routine immunizations and supplementary immunization activities, often integrated with Child Health Days. Collectively these activities were successful in reaching and sustaining a high enough proportion of the child population to achieve herd immunity and prevent measles transmission. Conclusions Additional efforts and resources are needed to continue pushing coverage up, particularly for measles immunization, in rural/hard-to-reach areas, amongst younger children, and less educated/poorer groups. In countries with low routine immunization coverage, Child Health Days are still needed.

Multi-country analysis of routine data from integrated community case management (iCCM) programs in sub-Saharan Africa.

Aim To identify better performing iCCM programs in sub–Saharan Africa (SSA) and identify factors associated with better performance using routine data. Methods We examined 15 evaluations or studies of integrated community case management (iCCM) programs in SSA conducted between 2008 and 2013 and with information about the program; routine data on treatments, supervision, and stockouts; and, where available, data from community health worker (CHW) surveys on supervision and stockouts. Analyses included descriptive statistics, Fisher exact test for differences in median treatment rates, the Kruskal-Wallis test for differences in the distribution of treatment rates, and Spearman’s correlation by program factors. Results The median percent of annual expected cases treated was 27% (1–74%) for total iCCM, 37% (1–80%) for malaria, 155% (7–552%) for pneumonia, and 27% (1–74%) for diarrhoea. Seven programs had above median total iCCM treatments rates. Four programs had above median treatment rates, above median treatments per active CHW per month, and above median percent of expected cases treated. Larger populations under–five targeted were negatively associated with treatment rates for fever, malaria, diarrhea, and total iCCM. The ratio of CHWs per population was positively associated with diarrhoea treatment rates. Use of rapid diagnostic tests (RDTs) was negatively associated with treatment rates for pneumonia. Treatment rates and percent of annual expected cases treated were equivalent between programs with volunteer CHWs and programs with salaried CHWs. Conclusions There is large variation in iCCM program performance in SSA. Four programs appear to be higher performing in terms of treatment rates, treatments per CHW per month, and percent of expected cases treated. Treatment rates for diarrhoea are lower than expected across most programmes. CHWs in many programmes are overtreating pneumonia. Programs targeting larger populations under–five tend to have lower treatment rates. The reasons for lower pneumonia treatment rates where CHWs use RDTs need to be explored. Programs with volunteer CHWs and those with salaried CHWs can achieve similar treatment rates and percent of annual expected cases treated but to do so volunteer programs must manage more CHWs per population and salaried CHWs must provide more treatments per CHW per month.

The role of ‘hidden’ community volunteers in community-based health service delivery platforms: examples from sub-Saharan Africa

Community-based research on child survival in sub-Saharan Africa has focussed on the increased provision of curative health services by a formalised cadre of lay community health workers (CHWs), but we have identified a particular configuration, that deserves closer scrutiny. We identified a two-tiered CHW system, with the first tier being the lessor known or ‘hidden’ community/village level volunteers and the second tier being formal, paid CHWs, in Ethiopia, Mali, and Niger. Whilst the disease-focussed tasks of the formal CHW tier may be more amenable to classic epidemiological surveillance, we postulate that understanding the relationship between formalised CHWs and volunteer cadres, in terms of scope, location of practice and ratio to population, would be important for a comprehensive evaluation of child survival in these countries. We report on the findings from our joint qualitative and quantitative investigations, highlighting the need to recognise the ‘hidden’ contribution of volunteers. We need to better characterize the volunteers’ interaction with community-based and primary care services and to better understand ways to improve the volunteer systems with the right type of investments. This is particularly important for considering the models for scale-up of CHWs in sub-Saharan Africa.

Identifying priorities for emergency intervention from child wasting and mortality estimates in vulnerable areas of the Horn of Africa.

Background The relation between anthropometric measures and mortality risk in different populations can provide a basis for deciding how malnutrition prevalences should be interpreted. Objective To assess criteria for deciding on needs for emergency interventions in the Horn of Africa based on associations between child wasting and mortality from 2000 to 2005. Methods Data were analyzed on child global acute malnutrition (GAM) prevalences and mortality estimates from about 900 area-level nutrition surveys from Ethiopia, Kenya, Somalia, Sudan, and Uganda; data on drought, floods, and food insecurity were added for Kenya (Rift Valley) and Ethiopia, from Food and Agriculture Organization (FAO) reports at the time. Results Higher rates of GAM were associated with increased mortality of children under 5 years of age (U5MR), more strongly among populations with pastoral livelihoods than with agricultural livelihoods. In all groups spikes of GAM and U5MR corresponded with drought (and floods). Different GAM cutoff points are needed for different populations. For example, to identify 75% of U5MRs above 2/10,000/day, the GAM cutoff point ranged from 20% GAM in the Rift Valley (Kenya) to 8% in Oromia or SNNPR (Ethiopia). Conclusions Survey results should be displayed as time series within geographic areas. Variable GAM cutoff points should be used, depending on livelihood or location. For example, a GAM cutoff point of 15% may be appropriate for pastoral groups and 10% for agricultural livelihood groups. This gives a basis for reexamining the guidelines currently used for interpreting wasting (or GAM) prevalences in terms of implications for intervention.

Routine monitoring systems for integrated community case management programs: Lessons from 18 countries in sub-Saharan Africa.

Integrated community case management (iCCM) programs are expanding rapidly in many low– and middle–income countries, particularly in sub–Saharan Africa. Conclusions from the recent review of iCCM programs in Africa emphasized the critical importance of using routine data to assess program performance and to inform impact evaluations [1]. Yet monitoring systems often fail to deliver quality data (defined as relevant, complete, timely and accurate [2]) and program managers do not have the capacity or are not empowered to use data for decision–making and corrective action [3]. Monitoring systems for iCCM suffer from many of the same shortcomings of the broader routine health information systems (HIS), but extending these systems to the community level at scale presents unique challenges and constraints. While the literature highlighting results of iCCM programs has expanded, little has been published that explores the monitoring systems necessary to support successful implementation. This paper aims to synthesize lessons learned from recent experience developing and implementing systems for routine monitoring of large scale iCCM programs. These lessons were compiled from the primary partners supporting iCCM implementation across 18 countries in sub–Saharan Africa through interviews with monitoring focal persons and review of relevant documents and tools and informed by literature on strengthening routine health information systems more broadly [3–5]. We first outline the rationale for routine data and the challenges iCCM programs face to establish functional monitoring systems to generate such data. We then characterize the current state of routine monitoring systems for iCCM, summarize lessons learned and conclude with a way forward.

Where to from here? Policy and financing of integrated community case management (iCCM) of childhood illness in sub-Saharan Africa.

Integrated community case management of childhood illness (iCCM) is a strategy to equip, train, support and supervise community health workers (CHWs) to assess children and deliver curative interventions in communities [1]. In particular, iCCM includes the delivery of amoxicillin (with use of respiratory timers) for pneumonia, oral rehydration salts and zinc for diarrhoea, and rapid diagnostic tests and artemisinin–based combination therapy for malaria. iCCM may also include screening, referral and treatment for malnutrition, and of newborns with illness. A “community health worker” (CHW) in this context is a health worker that provides health care in the community, with some training in the interventions they deliver (and who may or may not receive monetary payment), but who does not have a formal health professional or paraprofessional certificate or tertiary education degree. In sub–Saharan Africa, recent years have seen increasing recognition of iCCM as a core strategy to deliver care to children, particularly those with poor access to health facilities, and reduce child mortality, in the context of the drive to achieve the Millennium Development Goals. Twenty–eight countries in sub–Saharan Africa are now the site of delivery of community case management for each of pneumonia, diarrhoea and malaria, albeit at widely differing levels of coverage between countries [2]. Despite this progress, there are significant remaining obstacles to realizing the potential of iCCM to provide effective coverage of interventions for childhood illness at scale and quality. Here we review current trends in policy and financing of iCCM in sub–Saharan Africa to highlight two key issues: sustainable financing of iCCM, particularly from domestic sources, and the integration of iCCM in national health systems. We conclude by providing suggestions for how to move forward on these linked challenges.

Global implementation survey of Integrated Management of Childhood Illness (IMCI): 20 years on

Objective To assess the extent to which Integrated Management of Childhood Illness (IMCI) has been adopted and scaled up in countries. Setting The 95 countries that participated in the survey are home to 82% of the global under-five population and account for 95% of the 5.9 million deaths that occurred among children less than 5 years of age in 2015; 93 of them are low-income and middle-income countries (LMICs). Methods We conducted a cross-sectional self-administered survey. Questionnaires and data analysis focused on (1) giving a general overview of current organisation and financing of IMCI at country level, (2) describing implementation of IMCI’s three original components and (3) reporting on innovations, barriers and opportunities for expanding access to care for children. A single data file was created using all information collected. Analysis was performed using STATA V.11. Participants In-country teams consisting of representatives of the ministry of health and country offices of WHO and Unicef. Results Eighty-one per cent of countries reported that IMCI implementation encompassed all three components. Almost half (46%; 44 countries) reported implementation in 90% or more districts as well as all three components in place (full implementation). These full-implementer countries were 3.6 (95% CI 1.5 to 8.9) times more likely to achieve Millennium Development Goal 4 than other (not full implementer) countries. Despite these high reported implementation rates, the strategy is not reaching the children who need it most, as implementation is lowest in high mortality countries (39%; 7/18). Conclusion This survey provides a unique opportunity to better understand how implementation of IMCI has evolved in the 20 years since its inception. Results can be used to assist in formulating strategies, policies and activities to support improvements in the health and survival of children and to help achieve the health-related, post-2015 Sustainable Development Goals.

A proposed model to conduct process and outcome evaluations and implementation research of child health programs in Africa using integrated community case management as an example

Aim To use a newly devised set of criteria to review the study design and scope of collection of process, outcomes and contextual data for evaluations and implementation research of integrated community case management (iCCM) in Sub–Saharan African. Methods We examined 24 program evaluations and implementation research studies of iCCM in sub–Saharan Africa conducted in the last 5 years (2008–2013), assessed the design used and categorized them according to whether or not they collected sufficient information to conduct process and outcome evaluations. Results Five of the 24 studies used a stepped wedge design and two were randomized control trials. The remaining 17 were quasi–experimental of which 10 had comparison areas; however, not all comparison areas had a pre and post household survey. With regard to process data, 22 of the studies collected sufficient information to report on implementation strength, and all, except one, could report on program implementation. Most common missing data elements were health facility treatments, service costs, and qualitative data to assess demand. For the measurement of program outcomes, 7 of the 24 studies had a year or less of implementation at scale before the endline survey, 6 of the household surveys did not collect point of service, 10 did not collect timeliness (care seeking within 24 hours of symptoms) and 12 did not have socioeconomic (SES) information. Among the 16 studies with comparison areas, only 5 randomly selected comparison areas, while 10 had appropriate comparison areas. Conclusions Several evaluations were done too soon after implementation, lacked information on health facility treatments, costs, demand, timeliness or SES and/or did not have a counterfactual. We propose several study designs and minimal data elements to be collected to provide sufficient information to assess whether iCCM increased timely coverage of treatment for the neediest children in a cost–efficient manner.

Assessment of Malawi’s success in child mortality reduction through the lens of the Catalytic Initiative Integrated Health Systems Strengthening programme: Retrospective evaluation

Background Malawi is estimated to have achieved its Millennium Development Goal (MDG) 4 target. This paper explores factors influencing progress in child survival in Malawi including coverage of interventions and the role of key national policies. Methods We performed a retrospective evaluation of the Catalytic Initiative (CI) programme of support (2007–2013). We developed estimates of child mortality using four population household surveys undertaken between 2000 and 2010. We recalculated coverage indicators for high impact child health interventions and documented child health programmes and policies. The Lives Saved Tool (LiST) was used to estimate child lives saved in 2013. Results The mortality rate in children under 5 years decreased rapidly in the 10 CI districts from 219 deaths per 1000 live births (95% confidence interval (CI) 189 to 249) in the period 1991–1995 to 119 deaths (95% CI 105 to 132) in the period 2006–2010. Coverage for all indicators except vitamin A supplementation increased in the 10 CI districts across the time period 2000 to 2013. The LiST analysis estimates that there were 10 800 child deaths averted in the 10 CI districts in 2013, primarily attributable to the introduction of the pneumococcal vaccine (24%) and increased household coverage of insecticide–treated bednets (19%). These improvements have taken place within a context of investment in child health policies and scale up of integrated community case management of childhood illnesses. Conclusions Malawi provides a strong example for countries in sub–Saharan Africa of how high impact child health interventions implemented within a decentralised health system with an established community–based delivery platform, can lead to significant reductions in child mortality.