Malaria in PregnancyPopulation Interventions: Cochrane+ Review Atun R, de Jongh T, Secci F, et al, A...
Transcript of Malaria in PregnancyPopulation Interventions: Cochrane+ Review Atun R, de Jongh T, Secci F, et al, A...
© Professor Rifat Atun. Imperial College London 2012
Professor Rifat Atun MBBS MBA FRCGP FFPH FRCP Professor of International Health Management Imperial College Business School and Faculty of Medicine Imperial College London
Malaria in Pregnancy An analysis of achievements and limitations to meeting Women’s comprehensive needs during pregnancy Istanbul Imperial College London 26-28 June 2012
© Professor Rifat Atun. Imperial College London. 2012
Figure 1
Source: The Lancet 2010; 376:1485-1496 (DOI:10.1016/S0140-6736(10)61302-5)
ODA for maternal and newborn health for 68 Countdown priority countries, 2008
© Professor Rifat Atun. Imperial College London. 2012
Figure 3
Source: The Lancet 2010; 376:1485-1496 (DOI:10.1016/S0140-6736(10)61302-5)
ODA for maternal and newborn health per livebirth vs maternal mortality for 68 Countdown priority countries, 2008
© Professor Rifat Atun. Imperial College London. 2012
Figure 2
Source: Hay, Gething, Atun Snow. The Lancet 2010; 376:1409-1416 (DOI:10.1016/S0140-6736(10)61340-2)
Equity of funding for malaria control
© Professor Rifat Atun. Imperial College London. 2012
Figure 3
Source: Hay, Gething, Snow, Atun: The Lancet 2010; 376:1409-1416 (DOI:10.1016/S0140-6736(10)61340-2)
Adequacy of malaria funding
© Professor Rifat Atun. Imperial College London. 2012
Prevention, 42%
Treatment, 31%
Source: Global Fund, unpublished Enhanced Financial Reporting data, 2008
Global Fund Expenditures by Service Delivery Area for Malaria (cumulative, by 2008 reporting cycle)
Diagnosis, 2%
Other preven3ve ac3vi3es, 3%
Vector control (other than ITNs), 4%
Malaria preven3on during pregnancy, 2%
Home-‐based management of malaria, 1%
© Professor Rifat Atun. Imperial College London. 2012
© Professor Rifat Atun. Imperial College London. 2012
© Professor Rifat Atun. Imperial College London. 2012
Health innovations diffuse very slowly
• 1601: James Lancaster demonstrates lemon juice cures scurvy
• 1749: Repeated by Lind – 1753 “A treatise of the scurvy”
• 1795: Royal Navy acts on evidence • 1865: Merchant Navy acts on evidence
© Professor Rifat Atun. Imperial College London. 2012
Poor diffusion of innovation Use of antimalarial drugs in children <5
Source: DHS, MICS and MIS surveys conducted 2006-2008
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treated with other anti-malarial
treated with ACT
Slide source: WHO/GMP, WMR 2009
© Professor Rifat Atun. Imperial College London. 2012
Figure 2
Source: The Lancet 2010; 375:2032-2044 (DOI:10.1016/S0140-6736(10)60678-2)
© Professor Rifat Atun. Imperial College London. 2012
Coverage for interventions across the care continuum: 68 priority countries (2000‐06)
© Professor Rifat Atun. Imperial College London. 2012
Antenatal coverage and PMTCT uptake
Figure 3.12
Preventing mother-to-child transmissionCoverage of antenatal care services and services for preventing mother-to-child transmission among women living with HIV in high-prevalence countries, 2010
Source: WHO and UN Statistics Division
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AngolaBotswanaBurundiCameroonChadCôte d’IvoireD.R. CongoEthiopiaGhanaKenyaLesothoMozambiqueNigeriaSouth AfricaUgandaZambia
PMTCT coverage, ANC coverage and number of HIV+ pregnant women (bubble size)
Source: WHO and UN Statistics Division in UNAIDS Global Report 2010
© Professor Rifat Atun. Imperial College London. 2012
Figure 4
Source: The Lancet 2010; 375:2032-2044 (DOI:10.1016/S0140-6736(10)60678-2)
Proportion of livebirths attended by skilled personnel in 34 Countdown countries with nationally representative measurements around 2000 and around 2008
© Professor Rifat Atun. Imperial College London. 2012
Proportion of women attending antenatal care receiving second dose of IPTp (2010)
Source: WHO WMR 2011
© Professor Rifat Atun. Imperial College London. 2012
Proportion of all pregnant women receiving the second dose of IPTp (2009-11)
Source: WHO WMR 2011
© Professor Rifat Atun. Imperial College London 2012
Is integrated care delivery the solution to address poor uptake of innovations?
© Professor Rifat Atun. Imperial College London. 2012
Primary Community Secondary
Care domain
Services or programs
a. Unintegrated
Primary Community Secondary Primary Community Secondary
b. Partial integration c. Horizontal or vertical integration
Potential integration strategies within and across care domains
Atun et al.: Integration of priority population, health and nutrition interventions into health systems: systematic review. BMC Public Health 2011 11:780. 18
© Professor Rifat Atun. Imperial College London. 2012
Integrated delivery models – HNP interventions
Programme Intervention Outcome
IMCI (Adam 2005, Arifeen 2004, Bryce 2005, Armstrong Schellenberg 2004)
Multi-country CBA in 12 countries Integration of IMCI in services in vs. routine care
Improved case management, quality of care and under-5 mortality. Costs lower.
PRISM-E (Bartels 2004, Krahn 2006, Oslin 2006)
Integrated delivery of mental health and/or substance abuse services for elderly in PHC setting
Improved patient engagement
Substance abuse & PHC (Weisner 2001, Willenbring 1999
Substance abuse treatment with integrated medical treatment of substance abuse-related co-morbidities
Improved abstinence. Cost effective
Mental health provision in PHC (Gater 1997, Watts 2007)
Depression and schizophrenia treatment integrated into PHC
Improved access and treatment, resources more effectively used
Atun et al.: Integration of priority population, health and nutrition interventions into health systems: systematic review. BMC Public Health 2011 11:780.
© Professor Rifat Atun. Imperial College London. 2012
Integration of Targeted Health, Nutrition and Population Interventions: Cochrane+ Review
Atun R, de Jongh T, Secci F, et al, A systematic review of the evidence on integration of targeted health interventions into health systems. Health Policy & Planning 2010; 25 :1-14
© Professor Rifat Atun. Imperial College London. 2012
Integrated delivery of PMTCT: Cochrane Review
Tudor Car L, van-Velthoven MH, Brusamento S, Elmoniry H, Car J, Majeed A, Atun R, Integrating prevention of mother-to-child HIV transmission (PMTCT) programmes with other health services for preventing HIV infection and improving HIV outcomes in developing countries., Cochrane Database Systematic Review 2011
One study • Integra3ng HIV tes3ng and NVP
adherence assessment at labour ward resulted in substan3al increase in mother-‐infant NVP coverage.
• No research assessing the impact on coverage of integra3ng with other perinatal PMTCT interven3ons
© Professor Rifat Atun. Imperial College London. 2012
© Professor Rifat Atun. Imperial College London. 2012
Adoption of innovations:
global health systems at crossroads:
© Professor Rifat Atun. Imperial College London. 2012
Key barrier (1): linear view of innovation adoption
© Professor Rifat Atun. Imperial College London. 2012
Key barrier (2): limited evidence
Methodological challenges in generating evidence
What works in practice and what has worked less well
Optimal delivery models?
Scale and learning effects?
1
2
3
4
Suboptimal solutions
implemented Sources of resistance to policy translation
© Professor Rifat Atun. Imperial College London. 2012
Key barrier (3): imbalance in health and financing policies
Industrial policies encourage technology push, but health systems constrain innovation:
– Not enough emphasis on demand side factors – Inadequate incentives and downstream rewards
for adoption – Inefficiency/ineffectiveness tolerated – No incentives for innovation
Atun RA, Gurol-Urganci I, Sheridan D. Uptake and diffusion of pharmaceutical innovations in health systems. International Journal of Innovation Management 2007; 11 (2): 299-321
© Professor Rifat Atun. Imperial College London. 2012
Key barrier (4): institutional logic
• Resistance to innovation
• Overdue emphasis on technology innovation
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Technology overdrive
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© Professor Rifat Atun. Imperial College London. 2012
Innovative Mechanisms for Financing
Fisk NM, McKee M, Atun R. Relative and absolute addressability of global disease burden in maternal and perinatal health by investment in R&D. Trop Med Int Health 2011. Apr 7. doi: 10.1111/j.1365-3156.2011.02778.x.
© Professor Rifat Atun. Imperial College London. 2012
Diffusion of innovations in complex systems
Intervention Adoption System
Broad Context
Broad Context
Health System Characteristics
Problem
Atun R, et al. A systematic review of the evidence on integration of targeted health interventions into health systems. Health Policy and Planning 2010; 25: 1-14.
© Professor Rifat Atun. Imperial College London. 2012
A systems approach to innovation
1. Problem perception
2. Innovation
3. Adoption System
4. Health System
5. Context
• Burden • Necessity and urgency
• Complexity • Scalability
• Receptivity • Opportunity • Feasibility
• Desirability • Logic
Atun et al. Health Policy and Planning 2010
© Professor Rifat Atun. Imperial College London. 2012
Thank you