Rudolf Knippenberg

Systematic scaling up of neonatal care in countries

Every year about 70% of neonatal deaths (almost 3 million) happen because effective yet simple interventions do not reach those most in need. Coverage of interventions is low, progress in scaling up is slow, and inequity is high, especially for skilled clinical interventions. Situations vary between and within countries, and there is no single solution to saving lives of newborn babies. To scale up neonatal care, two interlinked processes are required: a systematic, data-driven decision-making process, and a participatory, rights-based policy process. The first step is to assess the situation and create a policy environment conducive to neonatal health. The next step is to achieve optimum care of newborn infants within health system constraints; in the absence of strong clinical services, programmes can start with family and community care and outreach services. Addressing missed opportunities within the limitations of health systems, and integrating care of newborn children into existing programmes--eg, safe motherhood and integrated management of child survival initiatives--reduces deaths at a low marginal cost. Scaling up of clinical care is a challenge but necessary if maximum effect and equity are to be achieved in neonatal health, and maternal deaths are to be reduced. This step involves systematically strengthening supply of, and demand for, services. Such a phased programmatic implementation builds momentum by reaching achievable targets early on, while building stronger health systems over the longer term. Purposeful orientation towards the poor is vital. Monitoring progress and effect is essential to refining strategies. National aims to reduce neonatal deaths should be set, and interventions incorporated into national plans and existing programmes.

Why are 4 million newborn babies dying each year

In the summer of 2003 The Lancet published five articles on child survival written by the Bellagio Child Survival Group. These publications have had tangible effects. A Global Partnership for Child Survival secretariat is being established to assist the development and implementation of plans to reduce child deaths in 42 countries that account for 90% of deaths in those younger than 5 years of age. Two national meetings in Ethiopia and Cambodia have been held to discuss strategies for implementing the interventions outlined in the Bellagio child-survival series. Other countries are revising their child health and survival programmes. Although the Bellagio series has had an important effect in the child-survival arena a major gap in information and action remains about deaths in the first 4 weeks of life—the neonatal period. The second half of the 20th century witnessed a remarkable reduction in child mortality with a halving of the risk of death before the age of 5 years. Most of this reduction however has been because of lives saved after the first 4 weeks of life with little reduction in the risk of death in the neonatal period for most babies worldwide. Neonatal deaths estimated at nearly 4 million annually now account for 36% of deaths worldwide in children aged under 5 years. Millenium Development Goal 4 (MDG-4) regarding child survival stipulates a reduction of two-thirds in deaths in children aged under 5 years from 95 per 1000 in 1990 to 31 per 1000 in 2015. Given that the current global neonatal mortality rate is estimated to be 31 per 1000 live-births8 a substantial reduction in neonatal deaths will be required to meet MDG-4. Reduction of neonatal deaths should become a major public-health priority. (excerpt)

1 year after The Lancet Neonatal Survival Series—was the call for action heard?

In March 2005 The Lancet published a series of four articles and two Comments highlighting a huge number of largely neglected deaths—the 4 million newborn babies who die every year of whom 99% are born in developing countries. 4 million is roughly the number of babies born every year in the USA or in the 23 largest countries of western Europe. It is also roughly the number of AIDS and malaria deaths combined in 1 year. Yet deaths in newborn babies are rarely mentioned in global-health priorities. A misconception has been that highly technical care is needed. On the contrary our estimates suggest that up to three-quarters of these deaths could be prevented with low-technology interventions at an additional cost of less than US

The comparative cost-effectiveness of an equity-focused approach to child survival, health, and nutrition: a modelling approach

1 per head for the 75 countries with the highest mortality. What is needed is the political will to ensure that these interventions reach the women and babies who need them. 1 year on we ask: what progress has been made over the past year in policy in funding and most importantly in programmes in high-mortality countries? Before discussing the commitments and events affecting newborn survival since March 2005 we have a caveat—measuring the effect on policy and practice is complex and attributing changes to The Lancet series is not possible and is not our aim. Our purpose is to promote and assess progress in reaching mothers and babies most in need. (excerpt)

Health seeking behaviour and household health expenditures in Benin and Guinea: the equity implications of the Bamako Initiative.

Progress on child mortality and undernutrition has seen widening inequities and a concentration of child deaths and undernutrition in the most deprived communities, threatening the achievement of the Millennium Development Goals. Conversely, a series of recent process and technological innovations have provided effective and efficient options to reach the most deprived populations. These trends raise the possibility that the perceived trade-off between equity and efficiency no longer applies for child health--that prioritising services for the poorest and most marginalised is now more effective and cost effective than mainstream approaches. We tested this hypothesis with a mathematical-modelling approach by comparing the cost-effectiveness in terms of child deaths and stunting events averted between two approaches (from 2011-15 in 14 countries and one province): an equity-focused approach that prioritises the most deprived communities, and a mainstream approach that is representative of current strategies. We combined some existing models, notably the Marginal Budgeting for Bottlenecks Toolkit and the Lives Saved Tool, to do our analysis. We showed that, with the same level of investment, disproportionately higher effects are possible by prioritising the poorest and most marginalised populations, for averting both child mortality and stunting. Our results suggest that an equity-focused approach could result in sharper decreases in child mortality and stunting and higher cost-effectiveness than mainstream approaches, while reducing inequities in effective intervention coverage, health outcomes, and out-of-pocket spending between the most and least deprived groups and geographic areas within countries. Our findings should be interpreted with caution due to uncertainties around some of the model parameters and baseline data. Further research is needed to address some of these gaps in the evidence base. Strategies for improving child nutrition and survival, however, should account for an increasing prioritisation of the most deprived communities and the increased use of community-based interventions.

Sustainability of primary health care including expanded program of immunizations in Bamako Initiative programs in West Africa: an assessment of 5 years' field experience in Benin and Guinea.

Curative and preventive care utilization in Bamako Initiative health centres in Guinea and Benin increased significantly. Service based data and household survey results are compared and interpreted to evaluate the equity aspects of the Bamako Initiative programmes in these settings. Improvements in the use of preventive services are shared by the richer and poorer groups of the population. Inequities are more apparent regarding curative area. An important part of the population is not using Bamako Initiative Health Centres for financial reasons. However, the poor were found to use these Health Centres relatively more than richer socio-economic groups. Challenges of the future are identified and recommendations made as to how to tackle the problem of true indigence.

Local cost sharing in Bamako Initiative systems in Benin and Guinea: assuring the financial viability of primary health care

In Togo Congo and Zaire which have experienced periods of political instability BI health centers have demonstrated relative resistance to the instability-- as long as drug supply was maintained services continued to be provided. These countries are now accelerating BI to rehabilitate their peripheral health systems. With the increasing adoption of BI or similar health system reform strategies in Africa there is an increasing need for empirical evidence of their impact on sustainability of PHC in the ``flagship countries. This series of articles attempts to: (i) clarify the sustainability concept and provide an operational definition of sustainability; (ii) summarize the operational strategies and enabling conditions for sustainability implemented in Benin and Guinea; and (iii) analyze the effectiveness efficiency financial viability and equity achieved between 1988 and 1993 by going to scale with the BI in Benin and Guinea. (excerpt)

Implementation of the Bamako Initiative: strategies in Benin and Guinea.

The fourth in a series of five, this article presents and analyses data on cost recovery and community cost-sharing, two key aspects of the Bamako Initiative which have been implemented in Benin and Guinea since 1986. The data come from approximately 400 health centres and result from the six-monthly monitoring sessions conducted from 1989 to 1993. Community involvement in the financing of local operating costs in the two national scale programmes is also described. In Benin and Guinea, a user fee system generates the community financed revenue with the aim of covering local operating costs including drugs. Health worker salaries remain the responsibility of the government and donor funding covers vaccine and investment costs. Village health committees manage and control resources and revenue. The community is also involved in decision making, strategy definition and quality control. In Benin in 1993, community financing revenue amounted to about US

Narrowing the gaps to meet the goals

0.6 per capita per year and generally covered all local recurrent non salary costs except vaccines and left a surplus. Although total costs and revenues were slightly lower in Guinea for the same period, over-all user fee revenue (around US

Affordability, cost-effectiveness and efficiency of primary health care: the Bamako Initiative experience in Benin and Guinea

0.3 per capita per year) covered local recurrent costs (not including salaries or vaccines). A comparison of costs and revenue between regions and individual health centres revealed important differences in cost recovery ratios. In Benin, some centres recovered more than twice the local costs targeted for community financing. Twenty-five per cent of centres in Guinea did not manage to cover their designated local recurrent costs. The longitudinal analysis showed that the level of cost recovery remained stable over time even as preventive care (and especially EPI) coverage rose significantly. To better understand the most important characteristics affecting cost recovery levels, best performing health centres in terms of cost-recovery levels in 1993 were compared to worst performing centres. This analysis showed that the size of the target population of the health centre is a key determinant of cost-recovery in both countries. In addition, in Guinea the utilization of curative care linked to geographical access and in Benin the average revenue per case linked to the number of deliveries proved to be additional factors of importance. In best performing centres, financial viability improved over time in both countries between 1990 and 1993. Finally, the implications of these conclusions for the planning of health centre revitalization in West Africa are discussed.