1. 1 OU July 2012 Child survival – how many deaths can we prevent and at what cost?

2. 2 OU July 2012 An evidence based approach to reducing under-5 deaths. Estimation of costs Actual experiences Child mortality and aspects to be covered Worldwide around 9 million children under 5 years of age are dying each year

3. 3 OU July 2012 Mortality by cause Interventions Impact on mortality Model A model for linking interventions to Impact on under-5 mortality Resources

4. 4 OU July 2012 Mortality by cause Impact on mortality Model Resources Interventions A model for linking interventions to Impact on under-5 mortality

5. 5 OU July 2012 24 countries in which over 90% of under-5 deaths occur Neonatal division Asphyxia - 29% Sepsis - 25% Tetanus - 7% Prematurity - 24% (Other is 15%)

6. 6 OU July 2012 Mortality by cause Impact on mortality Model Resources Interventions A model for linking interventions to Impact on under-5 mortality

7. 7 OU July 2012 Intervention selection Central criterion for selection of any intervention is feasibility for delivery at high levels of population coverage in low-income countries. Each potential intervention assigned to one of three levels based on the strength of evidence for its effect on child mortality. 1 – sufficient evidence of effect 2 – limited evidence of effect 3 – Inadequate evidence of effect

8. 8 OU July 2012 Interventions by cause - diarrhoea Exposure to diarrhoea Diarrhoea Survive Die Breastfeeding Complementary feeding Treatment Zinc Future: rotavirus vaccine Vitamin A Antibiotics for dysentry Oral rehydration therapy Zinc Water/San/Hygiene Prevention

9. 9 OU July 2012 Interventions, neonatal - prematurity Pregnant Premature Survive Die Insecticide-treated materials* Intermittent preventive therapy Newborn temperature management PreventionTreatment Antinatal steroids Antibiotics for premature rupture of membrane * Indoor residual spraying may be used as an alternative

10. 10 OU July 2012 Mortality by cause Impact on mortality Model Resources Interventions A model for linking interventions to Impact on under-5 mortality

11. 11 OU July 2012 For each of the 24 countries in sub-Saharan Africa, the number of under-5 deaths that could be prevented was calculated with coverage levels around the year 2000 increased to 99% except for exclusive breastfeeding, where 90% was used. The calculations divided into three types:  Exclusive and continuing breastfeeding, as this involved three levels: exclusive, partial and no breastfeeding  Complementary feeding, which utilized the underweight distribution of under-5s within a country  All other interventions. Lancet model – calculation types

12. 12 OU July 2012 For the majority of calculations the proportionate reduction of deaths when intervention coverage is increased from the current value (p c ) to target (p t ) is = A f E f (p t - p c )/(1 – p c E f ) where E f is the efficacy of the intervention and A f is the fraction of deaths affected by the intervention. Lancet model – calculation of deaths averted

13. 13 OU July 2012 Lancet model – parameters

14. 14 OU July 2012 Mortality by cause Impact on mortality Model Resources Interventions A model for linking interventions to Impact on under-5 mortality

15. 15 OU July 2012 Results are calculated on the basis of the situation in the year 2000. Under-5 deaths preventable through the universal application of the level 1 and 2 interventions were of three types – deaths preventable by:  individual intervention  specific cause  group of interventions Lancet model – results by intervention type

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19. 19 OU July 2012

20. 20 OU July 2012 Mortality by cause Interventions Impact on mortality Model Resources A model for linking interventions to Impact on under-5 mortality

21. 21 OU July 2012 Costing the reduction of under-5 deaths Costs are difficult to assess: Commission on Macro-economics and Health estimated US$7.5 billion, but not specifically for child mortality reduction Single disease estimates, such as HIV/AIDS, malaria and measles have been made, but little use for reduction of child mortality However, with publication of cause-of-death estimates and Lancet model on child deaths that could be averted through use of a package of effective interventions, more can be done on costing the achievement of the MDG on child survival

22. 22 OU July 2012 Source: Bryce et al, Can the world afford to save the lives of 6 million children each year? Lancet June 2005

23. 23 OU July 2012 Source: Bryce et al, Can the world afford to save the lives of 6 million children each year? Lancet June 2005

24. 24 OU July 2012 Source: Bryce et al, Can the world afford to save the lives of 6 million children each year? Lancet June 2005

25. 25 OU July 2012 Child mortality reduction: effects of varying assumptions on additional running costs Variable assessedLowHighLowHigh Country specific cost of community delivery agent relative to cost of a midwife (originally 75%) 50%100%43115955 Drug costs-25%+25%45985669 Existing intervention coverage level in year 2000 +25%-25%42106374 All three variables31118083 Variable value Additional annual running cost (US $ millions) Individual country costs and situations differ widely Source: Bryce et al, Can the world afford to save the lives of 6 million children each year? Lancet June 2005

26. 26 OU July 2012 Costing assumptions Average cost per death averted about $890, with neonatal death averted at around $780. But 2005 Lancet neonatal series estimated death averted cost of $2100 (over half of this due to provision of emergency obstetric care). Estimates did not include capital, hiring, training and other infrastructure development costs. Consumer costs were not included. Vaccines and drug cost estimates do not account for expected cost reduction as demand increases However, resources linked to appropriate intervention packages are critical if money is to be effectively used to reduce child mortality

27. 27 OU July 2012 Experiences in Africa

28. 28 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) Accelerated child survival and development (ACSD) in West Africa 11 countries in West Africa Support from CIDA and other partners Aim: To reduce mortality among children less than 5 years of age Strategy: Accelerate coverage with three packages of high- impact interventions, with a special focus on community- based delivery

29. 29 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) Three intervention packages Routine EPI+ Strengthening routine EPI Vitamin A supplementation Antenatal care+ (ANC+): Refocused ANC4 Tetanus immunization Intermittent presumptive treatment (IPT) against malaria Vitamin A (post partum) IMCI + Family practices promotion Exclusive breastfeeding ORT ITNs (pregnant and under-5s) Community management of malaria and ARI Concept and aim: three packages covering three service delivery modes, plus strengthening local accountabilities through performance contracts and participatory monitoring Started with limited package: EPI+ & ANC+ & ITNs

30. 30 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) ACSD geographic coverage Countries 4“high impact” Benin, Ghana, Mali, Senegal 7 “expansion” 16 “high impact”* (population ≈ 3million) 31 “expansion” (population ≈ 14 million) Districts *now 18 districts, because the Upper East Region of Ghana has been reorganized and now includes 8 rather than 6 districts.

31. 31 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) Evaluation questions Coverage 1. Were there changes in the ACSD “high-impact” districts? 2. Were these changes greater than in the comparison area? Impact 3. Were there changes in nutrition and mortality in the ACSD “high- impact” districts? 4. Were these changes greater than in the comparison area? Attribution 5. Is it plausible to attribute the impact found to ACSD?

32. 32 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) Evaluation design Intervention areas ACSD “high impact” countries/districts (Benin, Ghana, Mali, Senegal) Comparison areas All other districts in the country, excluding major metropolitan areas

33. 33 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) Data sources: All existing data that met quality standards

34. 34 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) ACSD Implementation EPI+ Immunizations and vitamin A supplementation implemented first and most strongly in all four countries ITNs started strong, but stockouts at UNICEF-Copenhagen limited provision of new nets for >1 year at crucial time IMCI+ Facility component received little support Community component started only in mid to late 2003 Many messages, some unlikely to affect child mortality Community tx of pneumonia not included at scale ACTs not available at community level in any of the three countries Interventions to address undernutrition given low priority ANC+ ACSD inputs focused on IPTp with SP and postnatal vitamin A

35. 35 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) Coverage for EPI+ interventions before and after ACSD, in HIDs Before ACSD After ACSD Key BeninGhana Mali Increases in coverage across the board in Ghana and Mali; Benin achieved increases for vitamin A and ITNs.

36. 36 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) Coverage for IMCI+ interventions before and after ACSD, in HIDs Before ACSD After ACSD Key No coverage gains, and some significant losses, in sick child care. Exclusive breastfeeding increased in Ghana, declined in Mali. BeninGhana Mali

37. 37 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) Coverage for ANC+ interventions before and after ACSD, in HIDs Before ACSD After ACSD Key Ghana and Mali improved care for childbearing women; delivery of TT and postnatal vit A benefited from EPI system in Mali. BeninGhana Mali

38. 38 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) Research question #1: Increases in coverage in ACSD HIDs?

39. 39 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) Under-five mortality in the ACSD HIDs Research question #3:

40. 40 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) Research question #4: Under-five mortality in the ACSD HIDs and national comparison areas

41. 41 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) Research question #5: Is it plausible to attribute the accelerated impact found to ACSD? Nutrition Benin: No impact found Ghana: Yes, for stunting, but only in period 1998 – 2003. Mali: No impact found Mortality Benin: No impact found Ghana: Unknown Mali: No impact found

42. 42 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) Conclusions (1) 1. Intervention coverage CAN be accelerated if there is adequate funding & human resources. 2. Acceleration of mortality declines require: a) Focus on interventions that have a large and rapid impact on major causes of child death b) Sufficient time to fully implement approach and for coverage to translate into declines in mortality and undernutrition c) Reasonable expectations, given level of resources

43. 43 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) Conclusions (2) 3. Policy barriers prevented key ACSD interventions directed at pneumonia and malaria from being fully implemented. 4. Breakdowns in commodities and gaps in funding vitiate progress toward impact. 5. More attention and operations research needed on incentives and supports for community-based workers

44. 44 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) Conclusions (3) 6. Careful monitoring with local capacity to use results is essential. 7. Evaluation improves programs and prospective evaluations are preferred to retrospective. 8. A new paradigm for impact evaluations is needed, that takes into account the absence of true comparison groups (see Lancet online July 9, 2010 – Victora, Black, Boerma & Bryce) See article: Lancet vol 375 pp 572-82, Feb.13, 2010

45. Changes to: Causes of under-5 deaths Interventions and their efficacy Under-5 mortality rate envelope Model used - LiST But there have been changes since the 2003 Lancet series on child survival

46. Lancet child survival series 2003 – paper 1, figure 5 Reference year: 2000, with 10.8 million under-5 deaths

47. Distribution of Causes of Child Deaths: Global Global (8.8 million under-5 deaths) Reference year: 2008 Global, regional, and national causes of child mortality in 2008: a systematic analysis, Lancet 375:1969, 2010

48. Distribution of Causes of Child Deaths: Sub-Saharan Africa Reference year: 2008

49. Distribution of Causes of Child Deaths: Southeast Asia Reference year: 2008

50. Major Changes in Estimation Methods in 2008 Compared with 2000-2003 New estimates of national mortality rates in children < 5 years and in neonates Multicause models increased datapoints (102→148) Considerable improvement in data sources, including use of national data for India and China Multicause model used instead of single-cause models for age-group of 1-59 months (similar to previous multicause neonatal model) Causes of death estimated for 193 countries compared with 42 countries in 2003 Lancet paper

51. Limitations Scarcity of COD data in highest U5MR countries –Medically certified vital registration available for 76 countries (4% of 8.8 million <5 deaths) –Evidence gap most acute for sub-Saharan Africa –Where mortality rates and need for data are the highest, resources and data are the lowest Estimates derived from statistical modelling include substantial uncertainty, but are useful for planning national health and nutrition efforts.

52. 52 OU July 2012 Three intervention packages Immunization “plus” (EPI + ITNs, deworming & vitamin A) ANC+ (Care for mother,TT, IPTp) IMCI+ (Improved management of pneumonia, malaria and diarrhea, and key family practices) Lives Saved Tool (LiST) Target users The tool is designed for use by country- and district-level policymakers, planners and managers in low- and middle-income countries, and by technical staff in partner organizations (NGOs, multilaterals, bilaterals). Tool highlights Use to investigate impact on child mortality of scaling up any combination of interventions, and estimate number of lives saved Change population, current intervention coverage, and patterns/causes of mortality to utilize different national or district data Run different scenarios and compare the results Compare across countries using different intervention package scenarios and coverage levels http://www.jhsph.edu/dept/IH/IIP/list/index.html Usage A series of articles have appeared in the BMC Public Health journal in 2011 on examples of usage of LiST

53. If we look more carefully we find a more complex situation. The next few slides give a hint of some of the challenges However, we have been looking primarily at national averages

56. East Asia and Pacific (excl. China) South Asia Middle East and North Africa CEE/CIS Sub-Sahara Africa Developing countries Note: Analysis is based on 68 developing countries with data on under-5 mortality rate by wealth quintile, accounting for 70% of total births in the developing world in 2008. Across all regions, under-5 mortality is higher in the poorest households Ratio of under-5 mortality rate: poorest 20% to richest 20% of households 0 123 2.8 2.7 2.6 2.1 1.9 2.2

57. Note: Proportional change of inequality in under-five mortality is measured by the proportional change of the ratio of under-five mortality rate between the poorest 20% and the richest 20% over time. Analysis based on 38 countries which have at least two DHS and have data on under-five mortality rate by wealth quintiles. Data from the two most recent DHS were used in the calculation for each country In many countries disparities in under-five mortality by wealth quintiles increased or remained the same with declining under- five mortality

58. 58 OU July 2012