Taghreed Adam

Evidence-based, cost-effective interventions: how many newborn babies can we save?

In this second article of the neonatal survival series, we identify 16 interventions with proven efficacy (implementation under ideal conditions) for neonatal survival and combine them into packages for scaling up in health systems, according to three service delivery modes (outreach, family-community, and facility-based clinical care). All the packages of care are cost effective compared with single interventions. Universal (99%) coverage of these interventions could avert an estimated 41-72% of neonatal deaths worldwide. At 90% coverage, intrapartum and postnatal packages have similar effects on neonatal mortality--two-fold to three-fold greater than that of antenatal care. However, running costs are two-fold higher for intrapartum than for postnatal care. A combination of universal--ie, for all settings--outreach and family-community care at 90% coverage averts 18-37% of neonatal deaths. Most of this benefit is derived from family-community care, and greater effect is seen in settings with very high neonatal mortality. Reductions in neonatal mortality that exceed 50% can be achieved with an integrated, high-coverage programme of universal outreach and family-community care, consisting of 12% and 26%, respectively, of total running costs, plus universal facility-based clinical services, which make up 62% of the total cost. Early success in averting neonatal deaths is possible in settings with high mortality and weak health systems through outreach and family-community care, including health education to improve home-care practices, to create demand for skilled care, and to improve care seeking. Simultaneous expansion of clinical care for babies and mothers is essential to achieve the reduction in neonatal deaths needed to meet the Millennium Development Goal for child survival.

The burden and costs of chronic diseases in low-income and middle-income countries

This paper estimates the disease burden and loss of economic output associated with chronic diseases-mainly cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes-in 23 selected countries which account for around 80% of the total burden of chronic disease mortality in developing countries. In these 23 selected low-income and middle-income countries, chronic diseases were responsible for 50% of the total disease burden in 2005. For 15 of the selected countries where death registration data are available, the estimated age-standardised death rates for chronic diseases in 2005 were 54% higher for men and 86% higher for women than those for men and women in high-income countries. If nothing is done to reduce the risk of chronic diseases, an estimated US

Cost effectiveness analysis of strategies for maternal and neonatal health in developing countries.

84 billion of economic production will be lost from heart disease, stroke, and diabetes alone in these 23 countries between 2006 and 2015. Achievement of a global goal for chronic disease prevention and control-an additional 2% yearly reduction in chronic disease death rates over the next 10 years-would avert 24 million deaths in these countries, and would save an estimated

Effectiveness and cost of facility-based Integrated Management of Childhood Illness (IMCI) in Tanzania

8 billion, which is almost 10% of the projected loss in national income over the next 10 years.

Implementation research: what it is and how to do it.

Abstract Objective To determine the costs and benefits of interventions for maternal and newborn health to assess the appropriateness of current strategies and guide future plans to attain the millennium development goals. Design Cost effectiveness analysis. Setting Two regions classified by the World Health Organization according to their epidemiological grouping: Afr-E, those countries in sub-Saharan Africa with very high adult and high child mortality, and Sear-D, comprising countries in South East Asia with high adult and high child mortality. Data sources Effectiveness data from several sources, including trials, observational studies, and expert opinion. For resource inputs, quantities came from WHO guidelines, literature, and expert opinion, and prices from the WHO choosing interventions that are cost effective database. Main outcome measures Cost per disability adjusted life year (DALY) averted in year 2000 international dollars. Results The most cost effective mix of interventions was similar in Afr-E and Sear-D. These were the community based newborn care package, followed by antenatal care (tetanus toxoid, screening for pre-eclampsia, screening and treatment of asymptomatic bacteriuria and syphilis); skilled attendance at birth, offering first level maternal and neonatal care around childbirth; and emergency obstetric and neonatal care around and after birth. Screening and treatment of maternal syphilis, community based management of neonatal pneumonia, and steroids given during the antenatal period were relatively less cost effective in Sear-D. Scaling up all of the included interventions to 95% coverage would halve neonatal and maternal deaths. Conclusion Preventive interventions at the community level for newborn babies and at the primary care level for mothers and newborn babies are extremely cost effective, but the millennium development goals for maternal and child health will not be achieved without universal access to clinical services as well.

Effect of the Integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a rural area in Bangladesh: a cluster randomised trial

BACKGROUND The Integrated Management of Childhood Illness (IMCI) strategy is designed to address major causes of child mortality at the levels of community, health facility, and health system. We assessed the effectiveness of facility-based IMCI in rural Tanzania. METHODS We compared two districts with facility-based IMCI and two neighbouring comparison districts without IMCI, from 1997 to 2002, in a non-randomised study. We assessed quality of case-management for childrens illness, drug and vaccine availability, and supervision involving case-management, through a health-facility survey in 2000. Household surveys were used to assess child-health indicators in 1999 and 2002. Survival of children was tracked through demographic surveillance over a predefined 2-year period from mid 2000. Further information on contextual factors was gathered through interviews and record review. The economic cost of health care for children in IMCI and comparison districts was estimated through interviews and record review at national, district, facility, and household levels. FINDINGS During the IMCI phase-in period, mortality rates in children under 5 years old were almost identical in IMCI and comparison districts. Over the next 2 years, the mortality rate was 13% lower in IMCI than in comparison districts (95% CI -7 to 30 or 5 to 21, depending on how adjustment is made for district-level clustering), with a rate difference of 3.8 fewer deaths per 1000 child-years. Contextual factors, such as use of mosquito nets, all favoured the comparison districts. Costs of childrens health care with IMCI were similar to or lower than those for case-management without IMCI. INTERPRETATION Our findings indicate that facility-based IMCI is good value for money, and support widespread implementation in the context of health-sector reform, basket funding, good facility access, and high utilisation of health facilities.

Methods to assess the costs and health effects of interventions for improving health in developing countries.

Implementation research is a growing but not well understood field of health research that can contribute to more effective public health and clinical policies and programmes. This article provides a broad definition of implementation research and outlines key principles for how to do it

Defining research to improve health systems.

BACKGROUND WHO and UNICEF launched the Integrated Management of Childhood Illness (IMCI) strategy in the mid-1990s to reduce deaths from diarrhoea, pneumonia, malaria, measles, and malnutrition in children younger than 5 years. We assessed the effect of IMCI on health and nutrition of children younger than 5 years in Bangladesh. METHODS In this cluster randomised trial, 20 first-level government health facilities in the Matlab subdistrict of Bangladesh and their catchment areas (total population about 350 000) were paired and randomly assigned to either IMCI (intervention; ten clusters) or usual services (comparison; ten clusters). All three components of IMCI-health-worker training, health-systems improvements, and family and community activities-were implemented beginning in February, 2002. Assessment included household and health facility surveys tracking intermediate outputs and outcomes, and nutrition and mortality changes in intervention and comparison areas. Primary endpoint was mortality in children aged between 7 days and 59 months. Analysis was by intention to treat. This study is registered, number ISRCTN52793850. FINDINGS The yearly rate of mortality reduction in children younger than 5 years (excluding deaths in first week of life) was similar in IMCI and comparison areas (8.6%vs 7.8%). In the last 2 years of the study, the mortality rate was 13.4% lower in IMCI than in comparison areas (95% CI -14.2 to 34.3), corresponding to 4.2 fewer deaths per 1000 livebirths (95% CI -4.1 to 12.4; p=0.30). Implementation of IMCI led to improved health-worker skills, health-system support, and family and community practices, translating into increased care-seeking for illnesses. In IMCI areas, more children younger than 6 months were exclusively breastfed (76%vs 65%, difference of differences 10.1%, 95% CI 2.65-17.62), and prevalence of stunting in children aged 24-59 months decreased more rapidly (difference of differences -7.33, 95% CI -13.83 to -0.83) than in comparison areas. INTERPRETATION IMCI was associated with positive changes in all input, output, and outcome indicators, including increased exclusive breastfeeding and decreased stunting. However, IMCI implementation had no effect on mortality within the timeframe of the assessment. FUNDING Bill & Melinda Gates Foundation, WHOs Department of Child and Adolescent Health and Development, and US Agency for International Development.

Cost-effectiveness analysis: can we reduce variability in costing methods?

Assessment of the cost effectiveness of interventions designed to achieve the millennium development goals for health is complex. The methods must be capable of showing the efficiency with which current and possible new resources are used, and incorporating interactions between concurrent interventions and the effect of expanding coverage on unit costs.1 They should also allow valid comparisons across a wide range of interventions. Here we describe how the standardised cost effectiveness methods used in the World Health Organizations Choosing Interventions that are Cost Effective (CHOICE) project have tackled these issues. The analysis was performed for 14 regions classified by WHO according to their epidemiological grouping (table A on bmj.com). The regional results (except if not relevant to the disease area, for example, malaria) are available at www.who.int/choice, but the papers in this series give details for just two regions: Afr-E, which includes countries in sub-Saharan Africa with high child mortality and very high adult mortality, and Sear-D, which comprises countries in South East Asia with high child and adult mortality.2–6 The term intervention is defined to include any preventive, promotive, curative, or rehabilitative action that improves health. Interventions are analysed individually and then in combinations or packages that could be undertaken together (box 1), taking into account interactions in costs or effectiveness, or both. Interventions were chosen for analysis either because they are commonly used or because disease control experts have advocated their introduction. In each case, some evidence was needed that the intervention could be effective. The list is not exhaustive, and excluding an intervention does not imply it is cost ineffective. All interventions and combinations are assessed assuming they are implemented for 10 years starting in 2000, the year the Millennium Declaration was signed. Good policy making would then require a reassessment of …

Republished research: Implementation research: what it is and how to do it: implementation research is a growing but not well understood field of health research that can contribute to more effective public health and clinical policies and programmes. This article provides a broad definition of implementation research and outlines key principles for how to do it.

Robert Terry and colleagues present working definitions of operational research, implementation research, and health systems research within the context of research to strengthen health systems.