CSHGP Program Learning Agenda: Maternal and

Newborn Health

Marge KoblinskySenior Maternal Health Advisor,

USAID CORE Group Fall Meeting

October 11, 20121

Presentation Outline

Purpose of consultancy Methods Findings from project reviews Conclusions and

recommendations

2

Purpose of Consultancy

Devise a prospective learning strategy to link NGO efforts in maternal/newborn health to global/national policy and strategy discourse

Highlight patterns of learning —the what and how -- guided by stakeholder needs, literature and capacity

3

Methods

Stakeholder Interests TAG—25 people Stakeholder interviews —10 people

Project doc review--purpose, avail data, conclusions Past (closed) projects — “intrapartum care

pkg”• Reviewed 17 projects>40% LOE MNCH; 5 in-depth

Current (active) projects (36) • Reviewed 4 with 100%MNC, OR grant (16>40% LOE

MNCH)

Global literature review – community MNH

4

CSHGP projects reviewed (N = 21)

5

STAKEHOLDER INTERESTS

6

Stakeholders’ main priorities

process of working with TBAs; effectiveness

effect of specific community approaches for improving implementation and access for MNH interventions

decision making re the selection of MNH intervention packages and the implementation approaches

costs of these interventions packages and approaches

CB-HMIS and its use in decision-making and costs of implementation

NGO contributions to strengthening referral systems

Postpartum and postnatal care: access and implementation 7

Findings: Stakeholder interests & availability of data

8

Topic

Stakeholder question

Indicators Project info/comments

TBAs -Process of working with TBAs

-New roles

-Best practice for TBAs

-How they link to big picture

-How effective are TBAS? What do they do?

% trained delivery attendant (Other Std MNC indicator)

-TBA not distinguished by indicator from any trained delivery attendant; not key word;

-Because of MOH policies TBA info not incorporated into project reports shared with MOH

- May have qual data and know # trained

FINDINGS FROM REVIEWS

-- COMPLETED PROJECTS-- OR PROJECTS

9

Proj purpose and data available

5 completed & 4 OR projects

10

Project info Data collected Comments

Purpose Enhance demand &/or quality of govt program-vulnerable

Vulnerable not generally defined

Study Design Pre-post ¾ OR –comparison area

Intervention package

DIP- planned; Complex interventions

Typically not stratified to test cpts of complex intervention; outputs not collected

Outcome data YES! (next slides)No cost data

Impact data Deaths not reported OR projects: may collect death data-VAs

Example of project inputs

Aim: Enhance demand and/or quality of govt programs (e.g., AKF Pak implementing CMW program of GOP; Nepal HealthRight—CB-NCP program of GON)

Interventions: Many known effective MNH interventions Delivered through trained, supervised skilled

works in setting with QI system Access: village comm; grp meeting, CHWs ,

TTBAs, savings groups, emergency transport plans

Awareness—comm mob, BCC, mass media11

Women delivered in a health facility in selected

CSHGP projects (13), base/endline surveys (%)

AMREF Kenya

HealthRight K

enya

Africare

Senegal

SC Malawi

PLAN Nepal

CARE Nepal

SC Vietnam

AKF India

HAI East

Timor

CWI Bangladesh

CARE Nica

ragua

Future G

eneratio

ns ...

INMED Peru0

20

40

60

80

100

Baseline Endline

Pe

rce

nt

(%)

AsiaLatin

AmericaAfrica

Changes in health facility deliveries: CSHGP grantee KPC and national DHS data

AM

REF

HealthR

ight

DH

S

Pla

n

CA

RE

DH

S

Futu

re

INM

ED

DH

S

KenyaNepal Peru

0

20

40

60

80

100

Pe

rce

nta

ge

(%

)

PVO KPC Change DHS National Change

CONCLUSIONS

14

Limitations of review

Sample projects reviewed may not be representative of all MNH projects in the portfolio

Copious project documentation restricted in-depth review

Variation in response to reporting guidance

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General Conclusions

Project information simply not easily accessible—spread over 500 or more pages• Needs to be captured in one relatively brief

document with objectives, methods, intervention description, results, discussion/interpretation, conclusion

Study design appropriate for question• Effectiveness studies—quasi exp design• OR—aim to improve implementation of a

known effective intervention16

Conclusions: Stakeholder interests

Effectiveness and cost effectiveness Standard projects not designed to

address questions of effectiveness/cost-effectiveness

Outputs not reported so don’t know adequacy of implementation • “Use data” e.g., of delivery kits, BPCR, not

widely available; relationship with use of SBA or facility not available

17

Learning to-date and Recommendations

1. Cross-cutting themes (e.g, Community case management)

2. Monitoring and evaluation of on-going projects

3. Operations research

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Conclusions: Project ReviewsLearning to-date

Cross-cutting themes (e.g, Community case management) • External person surveys the projects in

place/reviews project reports• Limited number of such efforts

• Potential topics:– What factors most affect the sustainability (or

integration) of community based approaches/interventions (e.g., CHW or TTBA outreach, women’s groups?

– What mechanisms are available for integrating such community approaches into the formal health system?

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Conclusions: Project ReviewsLearning to-date

Monitoring & evaluation of on-going projects• Pre-post surveys, specified indicators • Across project learning possible—and there are

increases in coverage noted (above)—but in individual project cannot state it was due to project inputs

• Potential M&E:– Are inputs and outputs on target to achieve the

desired outcomes: Specify at a population level– Who is the recipient of the interventions (equity)? – What contextual factors impact the projects? (eg.

Road density, transport available; supply availability) (see CI)

– Country case studies

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Conclusions: Project ReviewsLearning to-date

Operations Research Excellent beginning toward contributing

to global discourse Improve with more specificity, less

complex intervention packages and approaches

Potential OR:• Are community or professional providers

more appropriate for counseling messages? Where?

• Can new technologies (mobiles) improve community worker performance?

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Recommendations

OR projects What is of interest to local policy/program

managers? Collect right indicators at right levels—linking

inputs, activities, outputs, outcomes • Look beyond mortality at morbidity esp for MH• Develop quality of care indicators (eg.,

disrespect/abuse) Develop succinct reports accessible to outside

groups that follow normal journal requirements—and publish!

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General Recommendation

Decrease amount of time on descriptive info, increase time for analytical and interpretive information/project Project development stage -- formative

research/ analysis /writing Midterm–adequacy surveys that

measure inputs and outputs Final – evaluation survey plus 12 months

to analyze what happened/why, how to communicate results! 23

Many thanks to Jennifer Yourkevitch, Kirsten Unfried, Leo

Ryan, Nazo Kureshy

Thank you!

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