Community-based Approaches to Improving Reproductive, Maternal, Neonatal and Child

Health: Current Status of the Evidence

Henry Perry, Department of International Health

Spring CORE Group Meeting, 8 May 2014

Outline

• Rationale for the review• Components of the review process• Findings• A framework for improving RMNCH through

community-based approaches• The way forward

Rationale for the Review

• Rapidly expanding evidence base• Increasing interest in CBPHC• Need to begin to develop a more holistic

(integrated) approach to programming• The follow-on to USAID-supported MCHIP

(RMNCH) is now starting up

Components of the Review

• General review of any (peer-reviewed or grey) literature on community-based approaches to provision of RMNCH services (465 articles)

• Review of projects/programs/field studies that assessed the effectiveness of CBPHC in improving child health (476 assessments) or maternal health (119 assessments)

• Factors related to effective CHW programming and national CHW program case studies

Review Process

• Evidence-based review of effectiveness of CBPHC in improving child health

• Large-scale CHW program review• Evidence-based review of effectiveness of

CBPHC in improving maternal health• Broad literature review of promising

approaches to RMNCH

Findings: General Literature Review

Newly Emerging Interventions for Community-based Delivery

• Chlorhexidene umbilical cord care• Misoprostol for prevention of PPH• Zinc + ORS• iCCM• Participatory women’s groups

(PLA, Care Groups)• Home-based neonatal care (+ PP FP)• HIV/AIDs prevention, detection, treatment

(particularly for PMTCT)

Mainstay Interventions for Community-based Delivery

• Immunizations• Vitamin A supplementation• Breastfeeding/appropriate

complementary feeding• Maternal health (multiple

micronutrients, nutritional supplementation during pregnancy, ANC, clean delivery, delivery by a skilled attendant, promotion of facility-based delivery)

• CCM of childhood pneumonia

• Prevention and treatment of malaria (ITNs, IPT, CCM)

• CMAM

Broader Reproductive Health Interventions that Can Be Provided through Community-based

Approaches

• Family planning• Support for women living with AIDS• Cervical cancer screening and treatment• Harm reduction from unsafe abortion• Detection and treatment of syphilis

Evidence from Integrated Programs

• PVO child survival projects• Care Group projects• Jamkhed/India, Hospital Albert

Schweitzer/Haiti, Matlab/Bangladesh, SEARCH/India

• BRAC/Manoshi/Bangladesh

Evidence from Country Successes• Bangladesh

• Nepal

Lancet2013

Ethiopia

Brazil

Strengthening Community-based Service Delivery

• Community-based facilities

• Informal and traditional providers

Community Engagement and Community Partnerships

• Examples– Community-Directed Interventions• Initially for neglected tropical diseases but now moving

into RMNCH

• Descriptions of processes– Manoshi

Practical Findings from Operations Research

• Need to focus on main causes of mortality in order to demonstrate a decline in mortality– Evaluation of UNICEF West Africa programs with evidence of increased

coverage but no mortality impact (Bryce et al., Lancet, 2010)– Evaluation of home-based neonatal care program in Bangladesh

(Darmstadt et al., 2010)• Need to achieve a certain intensity of women’s participatory

groups for PLA – Program intensity in Ethiopia related to program outcomes (Karim et

al., PLOS 2013)– For PLA groups, need to reach 30% of mothers (Fottrell et al., JAMA

Pediatrics 2013)• Lack of supervision and logistical support are pervasive

Financial Aspects

• Innovative approaches to financing• Cost-effectiveness limited except for some on

a few specific interventions

Monitoring and Evaluation

• Practical approaches to assessing effectiveness of large-scale programs

• Monitoring coverage• LiST• Mortality assessment (measurement of changes in

mortality rate, verbal medical and social autopsy)• Strengthening M&E of large-scale CHW programs

(with transparent independent assessments every 5 years or so)

Emerging Issues

• Mental health for WRA• Gender-based violence (including FGM)• Other diseases of WRA (HIV/AIDS, TB, malaria,

chronic diseases)• Injuries

Cross-cutting Themes

• Urban health• Scaling up programs• Equity• Health systems strengthening• RMNCH in post-disaster relief and settings

with political conflict

Policy and Philosophical Issues

• The role of NGOs in fostering community engagement, community mobilization, community-based service delivery, training and support of CHWs

• Restoring a better balance between vertical and horizontal programming

• Strengthening the effectiveness of frontline workers and large-scale CHW programs

• Creating a more favorable policy environment

Conceptual Approaches

• CBIO• Aggressive home visitation with early

treatment of childhood illness

Findings from Effectiveness Review

Practical Program Strategies

• Intervention delivery– Home visits– Participatory women’s groups– Community-case management– Provision of services by mobile teams based at

peripheral facilities

Strategies for Village-wide Community Empowerment/Mobilization/

Demand Creation• Advocacy meetings with community leaders• Promotion and support of village health committees, village

development committees, and sanitation committees• Community-wide meetings• Community-directed interventions• Village health days/malaria awareness days, etc.• Health talks at Friday mosque gatherings, church meetings, etc.• Sharing locally obtained health-related data with the community• Involving men and older family members (e.g., mothers-in-laws)

Strategies for Community Empowerment/ Mobilization/Demand Creation in Groups

• Formation and training of women’s groups (community health clubs, pregnant women’s support groups, mothers’ centers/mothers’ committees, Care Groups, PLA Groups, self-help groups, women’s action groups, counseling and support groups)

• Formation of parent committees• Formation of adolescent groups• Formation of farmers’ clubs• Conditional cash transfers to eligible mothers• Savings and loan groups (microcredit)

Health System Strengthening Approaches

• Training of staff – frontline workers, CHWs, TBAs• Develop or upgrade peripheral facilities, strengthen quality of

care• Strengthen drug supply chain• Strengthen linkages between CHWs and peripheral facilities• Strengthen referral system

Strategies for Program Design, Identification of Target Groups, Surveillance

• Formative research/appreciative inquiry/PLA/stakeholder analysis

• Village registers (pregnancies, pregnancy outcomes, births, deaths, TB patients)

• Verbal autopsies• Client-held cards (maternal health cards, road-to-health cards,

child health cards, immunization cards)• KPC surveys

Educational Strategies

• Peer-to-peer counseling• Visual aids• mHealth• Skits, stories, games• Targeting grandmothers• Positive deviance inquiry/identifying strong community-level

workers to support others not as strong

Review of Large-scale Community Health Worker Programs

• The final version will be available on the MCHIP website next week:

http://www.mchip.net/chwreferenceguide

Creating a Framework for Sustainable Improvements in RMNCH at Scale through CBPHC

Community engagement, etc.

Paradigm Shift

• Approaching the community as a resource and partner, not a target of programs or passive recipient of services

• Investing in CBPHC as the priority for health systems strengthening and improving population-level health

The Way Forward

• Entry points– Policy (e.g., for task shifting, etc.)– Creation of “friendly” environment for CBPHC, community

engagement and NGOs– Supporting the development and assessment of “model”

integrated RMNCH programs – Supporting literature reviews/analyses of existing data– Continued research on current and new interventions– Operations research/translating policy and research into

action/implementation research/efficacy to effectiveness research/research on CHW programs

– Replication and scaling up of promising approaches

Acknowledgments

• MCHIP/USAID • Jim Ricca, Nazo Kureshy and others at USAID

and MCHIP who supported this work• Working Group on Community-based Primary

Health Care of the International Section of the American Public Health Association

• USAID, UNICEF, WHO, World Bank and Future Generations for support of the effectiveness review