1 OU July 2012 Child survival – how many deaths can we prevent and at what cost?
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Transcript of 1 OU July 2012 Child survival – how many deaths can we prevent and at what cost?
1OU July 2012OU July 2012
Childsurvival – how many
deaths can we prevent and
at what cost?
2OU 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
3OU July 2012
Mortality by cause
Interventions
Impact on mortality
Model
A model for linking interventions to Impact on under-5 mortality
Resources
4OU July 2012
Mortality by cause
Impact on mortality
ModelResources
Interventions
A model for linking interventions to Impact on under-5 mortality
5OU July 2012
0%
5%
10%
15%
20%
25%
30%
Diarrh
ea
Pneum
onia
Mea
sles
Mala
ria
HIV/A
IDS
Neona
tal
Other
Cause
Pe
rcen
t
Under-five deaths by cause, 2000Sub-Saharan Africa
24 countries in which over 90% of under-5 deaths occur
Neonatal division
Asphyxia - 29%
Sepsis - 25%
Tetanus - 7%
Prematurity - 24%
(Other is 15%)
6OU July 2012
Mortality by cause
Impact on mortality
ModelResources
Interventions
A model for linking interventions to Impact on under-5 mortality
7OU 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
8OU July 2012
Interventions by cause - diarrhoea
Exposure to diarrhoea
Diarrhoea
SurviveDie
Breastfeeding
Complementary feeding
Treatment
Zinc
Future: rotavirus vaccine
Vitamin AAntibiotics for dysentry
Oral rehydration therapy
Zinc
Water/San/Hygiene
Prevention
9OU July 2012
Interventions, neonatal - prematurity
Pregnant
Premature
SurviveDie
Insecticide-treated materials*Intermittent preventive therapy
Newborn temperature management
Prevention Treatment
Antinatal steroids
Antibiotics for premature rupture of membrane
* Indoor residual spraying may be used as an alternative
10OU July 2012
Mortality by cause
Impact on mortality
ModelResources
Interventions
A model for linking interventions to Impact on under-5 mortality
11OU 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
12OU July 2012
For the majority of calculations the proportionate reduction of deaths when intervention coverage is increased from the current value (pc) to target (pt) is
= AfEf(pt - pc)/(1 – pcEf)
where Ef is the efficacy of the interventionand Af is the fraction of deaths affected by the intervention.
Lancet model – calculation of deaths averted
13OU July 2012
Malaria
Evid. level Intervention
Current coverage
Target coverage Efficacy
Affected fraction
1 P1Complementary feeding by country
shift of N z-score towards
mean by country
1 P2 ITM by country 0.99 0.75malaria
countries only
2 P3 Vitamin A by country 0.99 0.44
by country (and only for 6
months plus)
2 P4 Zinc 0 0.99 0.36 by country
1 T5 Anti-malarials by country 0.99 0.67malaria
countries only
Lancet model – parameters
14OU July 2012
Mortality by cause
Impact on mortality
ModelResources
Interventions
A model for linking interventions to Impact on under-5 mortality
15OU 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
16OU July 2012
Percent of total deaths averted by single interventions - prevention
0% 2% 4% 6% 8% 10% 12% 14% 16% 18%
Insecticide-treated materials
Breastfeeding
Complementary feeding
Zinc
Hib vaccine
Clean delivery
Nivirapine & replacement feeding
Water/San/Hygiene
Vitamin A
Antenatal steroids
Measles vaccine
Newborn temperature management
Tetanus toxoid
Antibiotics - PRM
Antimalarial IPT in pregnancy
Inte
rven
tion
PercentSub-Saharan Africa
17OU July 2012
Percent of total deaths averted by single interventions - treatment
0% 2% 4% 6% 8% 10% 12% 14% 16%
Oral rehydrationtherapy
Antimalarials
Antibiotics -pneumonia
Antibiotics - sepsis
Zinc
Antibiotics -dysentery
Newbornresuscitation
Vitamin A
Inte
rven
tion
PercentSub-Saharan Africa
18OU July 2012
Preventable under-five deaths by causeSub-Saharan Africa
Disease or condition
Under-five deaths (in '000s) 2000
Percent of total under-five deaths
Number (in '000s) Percent
Diarrhoea 815 20% 720 88%Pneumonia 878 22% 583 66%Measles 77 2% 77 100%Malaria 889 22% 806 91%HIV/AIDS 288 7% 139 48%Neonatal 1020 25% 573 56%
Asphyxia 296 7% 115 39%Prematurity 245 6% 155 63%Severe infections 255 6% 244 96%Tetanus 71 2% 59 83%Other 153 4% 0 0%
Other 92 2% 0 0%TOTAL 4070 100% 2898 71%
Preventable under-five deaths
19OU July 2012
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Health facilitycentric
Health facilityoutreach
Home care
Location type
Per
cent
Interventions by locationHealth facility centric includes: antenatal steroids, temperature management, antibiotics-PRM, antibiotics-pneumonia, antibiotics-sepsis, rescusitation, antibiotics-dysentry, zinc-T and vitA-THealth facility outreach includes: zinc, hib vaccine, vitA, tetanus toxoid, nivirapine, clean delivery, measles, IPT and antimalarialsHome care includes: breastfeeding, complementary feeding, ITM and ORT
Sub-Saharan Africa
Percent of deaths averted by location of interventions
20OU July 2012
Mortality by cause
Interventions
Impact on mortality
ModelResources
A model for linking interventions to Impact on under-5 mortality
21OU 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
22OU July 2012
Under-five deaths averted and related costs(Application of single interventions only)
Intervention
Deaths averted
(in '000s)
Percent (of total deaths)
For 2000 coverage
levels
Additional for universal coverage
Breastfeeding 1301 13% 102 414Insecticide-treated materials 691 7% 1 77Complementary feeding 587 6% 46 158Zinc 459 5% 0 301Clean delivery 411 4% 502 653Hib vaccine 403 4% 66 1051Water/San/Hygiene 326 3% 1889 753Antenatal steroids 264 3% 61 420Newborn temperature management 227 2% 19 79Vitamin A 225 2% 129 271Tetanus toxoid 161 2% 71 161Nivirapine & replacement feeding 150 2% 1 82Antibiotics - PRM 133 1% 44 52Measles vaccine 103 1% 39 30Antimalarial IPT in pregnancy 22 0% 0 26Total 2970 4528(Global - 42 countries with 90% of all under-5 deaths)
Estimated annual running costs (millions US $)Prevention
Source: Bryce et al, Can the world afford to save the lives of 6 million children each year? Lancet June 2005
23OU July 2012
Under-five deaths averted and related costs(Application of single interventions only)
Intervention
Deaths averted
(in '000s)
Percent (of total deaths)
For 2000 coverage
levels
Additional for universal coverage
Additional cost as %
of sum
Breastfeeding 1301 13% 102 414 9%Insecticide-treated materials 691 7% 1 77 2%Complementary feeding 587 6% 46 158 3%Zinc 459 5% 0 301 7%Clean delivery 411 4% 502 653 14%Hib vaccine 403 4% 66 1051 23%Water/San/Hygiene 326 3% 1889 753 17%Antenatal steroids 264 3% 61 420 9%Newborn temperature management 227 2% 19 79 2%Vitamin A 225 2% 129 271 6%Tetanus toxoid 161 2% 71 161 4%Nivirapine & replacement feeding 150 2% 1 82 2%Antibiotics - PRM 133 1% 44 52 1%Measles vaccine 103 1% 39 30 1%Antimalarial IPT in pregnancy 22 0% 0 26 1%Total 2970 4528(Global - 42 countries with 90% of all under-5 deaths)
Estimated annual running costs (millions US $)Prevention
Source: Bryce et al, Can the world afford to save the lives of 6 million children each year? Lancet June 2005
24OU July 2012
Under-five deaths averted and related costs(Application of single interventions only)
Intervention
Deaths averted
(in '000s)
Percent (of total deaths)
For 2000 coverage
levels
Additional for universal coverage
Additional cost as %
of sum
Oral rehydration therapy 1477 15% 29 124 12%Antibiotics - sepsis 583 6% 101 17 2%Antibiotics - pneumonia 577 6% 290 332 32%Antimalarials 467 5% 200 46 4%Zinc 394 4% 0 150 14%Newborn resuscitation 359 4% 19 35 3%Antibiotics - dysentery 310 3% 284 333 32%Vitamin A 8 0% 52 0 0%Total 975 1037(Global - 42 countries with 90% of all under-5 deaths)
TreatmentEstimated annual running
costs (millions US $)
Source: Bryce et al, Can the world afford to save the lives of 6 million children each year? Lancet June 2005
25OU July 2012
Child mortality reduction: effects of varying assumptions on additional running costs
Variable assessed Low High Low High
Country specific cost of community delivery agent relative to cost of a midwife (originally 75%)
50% 100% 4311 5955
Drug costs -25% +25% 4598 5669
Existing intervention coverage level in year 2000
+25% -25% 4210 6374
All three variables 3111 8083
Variable valueAdditional 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
26OU 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
27OU July 2012
Experiences in Africa
28OU 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
29OU 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
30OU 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)
Mali
ChadNiger
Nigeria
Cameroon
Central AfricanRepublic
Congo - Democratic Republic
Congo
SenegalCape Verde
Gabon
Equatorial Guinea
Sao Tome &Principe
GambiaGuinea Bissau
Guinea
Sierra Leone
Liberia
Burkina Faso
Ghana
TogoBenin
High Impact Package
EPI + Expansion
Accelerated Child Survival Accelerated Child Survival and and DevelopmentDevelopment
CIDA CIDA funded projectfunded project
Côte d’Ivoire
Mauritania
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.
31OU 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
Coverage1. Were there changes in the ACSD “high-impact” districts?
2. Were these changes greater than in the comparison area?
Impact3. Were there changes in nutrition and mortality in the ACSD “high-
impact” districts?
4. Were these changes greater than in the comparison area?
Attribution5. Is it plausible to attribute the impact found to ACSD?
32OU 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
33OU 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
34OU 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 mortalityCommunity tx of pneumonia not included at scaleACTs 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
35OU 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+ interventionsbefore and after ACSD, in HIDs
Before ACSD
After ACSD
Key
Benin Ghana Mali
51
63
10
6
49
60
61
26
Measles
DPT
Vitamin A
ITNs
Increases in coverage across the board in Ghana and Mali; Benin achieved increases for vitamin A and ITNs.
36OU 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+ interventionsbefore 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.
Benin Ghana Mali
37OU 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+ interventionsbefore and after ACSD, in HIDs
Before ACSD
After ACSD
Key
71
0
44
76
5
64
7
55
74
38
3+ antenatal care visits
IPTp with SP
Tetanus Toxoid
Skilled attendant at delivery
Postnatal vit A
Ghana and Mali improved care for childbearing women; delivery of TT and postnatal vit A benefited from EPI system in Mali.
Benin Ghana Mali
38OU 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?
39OU 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:
40OU 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
41OU 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
42OU 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
43OU 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
44OU 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
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
Lancet child survival series 2003 – paper 1, figure 5
Reference year: 2000, with 10.8 million under-5 deaths
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
Distribution of Causes of Child Deaths: Sub-Saharan Africa
Reference year: 2008
Distribution of Causes of Child Deaths: Southeast Asia
Reference year: 2008
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
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.
52OU 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 usersThe 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
UsageA series of articles have appeared in the BMC Public Health journal in 2011 on examples of usage of LiST
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
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 1 2 3
2.8
2.7
2.6
2.1
1.9
2.2
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
58OU July 2012