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Lives Saved Tool: Using Li. ST for Maternal, Newborn, and Child Health Advocacy Koki Lives Saved Tool: Using Li. ST for Maternal, Newborn, and Child Health Advocacy Koki Agarwal, Director Rebecca Levine, Program Officer Maternal and Child Health Integrated Program

The Maternal and Child Health Integrated Program (MCHIP) • USAID Bureau for Global Health’s The Maternal and Child Health Integrated Program (MCHIP) • USAID Bureau for Global Health’s flagship maternal, newborn and child health program • Working in well over 30 countries worldwide • MCHIP supports programming and opportunities for integration in: • Maternal, Newborn and Child Health • Immunization, Family Planning, Malaria, HIV/AIDS • Wat/San, Urban Health, Health Systems Strengthening

Session Outline • Advocacy Tools for Global Health • Overview of Lives Saved Tool Session Outline • Advocacy Tools for Global Health • Overview of Lives Saved Tool (Li. ST) • Benefits & Limitations of Li. ST • How Li. ST has been used for Global Health Advocacy • How MCHIP has used Li. ST for Advocacy • Recommendations based on Experience

GLOBAL HEALTH ADVOCACY TOOLS GLOBAL HEALTH ADVOCACY TOOLS

What Tools Exist for Global Health Advocacy? • REDUCE An advocacy model for reducing What Tools Exist for Global Health Advocacy? • REDUCE An advocacy model for reducing maternal mortality, morbidity, and disability. Developed by the SARA Project. § Safe Motherhood Model A computer program to examine the impact of maternal health services on the maternal mortality ratio • ALIVE An advocacy model for saving newborn lives • Marginal Budgeting for Bottlenecking (MBB) Aims at estimating the potential impact, resources needs, costs and budgeting implications of country strategies to remove implementation constraints of the health system.

WHAT IS THE LIVES SAVED TOOL? WHAT IS THE LIVES SAVED TOOL?

The Lives Saved Tool - Li. ST Goal of Li. ST To promote evidence-based The Lives Saved Tool - Li. ST Goal of Li. ST To promote evidence-based decision making and aid in the planning for expansion of maternal, neonatal and child health interventions Objectives To estimate potential lives saved when introducing or scaling up key MNCH interventions 7

The Lives Saved Tool - Li. ST § The Lives Saved Tool § A The Lives Saved Tool - Li. ST § The Lives Saved Tool § A computer-based software that models multi-causes of mortality § Predicts changes in § Under-five and neonatal mortality rates and deaths § Maternal mortality ratios and deaths § Causes of death § Based on changes in health intervention coverage levels § Using § § Country specific fertility and HIV information and trends Country specific health status information Effect sizes of interventions (based on RCT studies) Baseline intervention coverage values (60+)

Which Interventions Are Included? § Proximal factors § Not distal (being equal) § Work Which Interventions Are Included? § Proximal factors § Not distal (being equal) § Work through health programs § Not included: income, education and crowding, etc. § Water and sanitation are the exceptions § Feasible in a low income country § 68 priority countries with highest MNCH mortality § Cause-specific evidence of effect § Research studies or systematic reviews § Delphi method if research is impossible (i. e. CEm. OC) § Updated as new evidence is published § Several published International Journal of Epidemiology (Apr 2010)

Intervention Types § Maternal, neonatal, child ex. AMTSL, Neonatal Resuscitation, Rotavirus vaccine § Periconceptional, Intervention Types § Maternal, neonatal, child ex. AMTSL, Neonatal Resuscitation, Rotavirus vaccine § Periconceptional, antenatal, birth, immediate postnatal, child ex. Folic acid supplementation, IPTp malaria, delivery care, routine postnatal care, antimalarials § Preventive, curative ex. Vitamin A, Pneumonia case management § Immediate, time-lagged ex. ORS, breastfeeding

What’s NOT Calculated in Li. ST? § § § § Education Motivation Gender issues What’s NOT Calculated in Li. ST? § § § § Education Motivation Gender issues Economic status Emergencies (i. e. famine, flooding) Delivery mechanism Quality of care

What Information Can Li. ST Provide? § Number of deaths § Total, by cause, What Information Can Li. ST Provide? § Number of deaths § Total, by cause, by age group § Mortality rates/ratios (NMR, U 5 MR, MMR) § Deaths averted (Lives Saved) § Total, by cause, by intervention, by age group § Intermediate outcomes § Stunting, breastfeeding § Displays (over a chosen period of time) § Tables, graphs, pie charts § Single country, multiple scenarios within one country § Multiple countries, single or multiple scenarios

Some Limitations of Li. ST § Data availability • If no baseline, can’t evaluate Some Limitations of Li. ST § Data availability • If no baseline, can’t evaluate impact accurately § Data quality § User Friendliness § Sensible scale up targets • Feasible, acceptable, funds available § Interventions included in software § Costing/budgeting considerations* * Links to existing costing tools including MBB and the WHO supported costing tool for child survival are being developed

Using Li. ST for Advocacy Using Li. ST for Advocacy

The Lancet South Africa series – August 2009 The Lancet, Volume 374, Issue 9692, The Lancet South Africa series – August 2009 The Lancet, Volume 374, Issue 9692, Pages 835 - 846, 5 September 2009 NEONATAL -Obstetric care packages -Resuscitation -Kangaroo mother care -Facility case mx of neonatal illness 12, 200 lives saved in 2015 PMTCT 37, 000 lives -Dual therapy "We cannot allow a single…neonate to die because of oursaved in negligence. . . it will be criminal for -Appropriate feeding us to allow any of these things to happen. “ Minister of Health Dr Aaron Motsoaledi, South Africa Source: Chopra M, Lawn et al Lancet 2009 2015

National situation analyses for newborn health in Africa National as well as sub-national analysis National situation analyses for newborn health in Africa National as well as sub-national analysis e. g. 36 states in Nigeria, 3 regions in Mali, South Sudan

“Science in Action” African Science Academies Development Initiative http: //www. nationalacademies. org/asadi/2009_Conference/PDFs/Science. In. Action. “Science in Action” African Science Academies Development Initiative http: //www. nationalacademies. org/asadi/2009_Conference/PDFs/Science. In. Action. Full. Report. pdf Coverage of skilled attendance at birth 9 example countries Total maternal, neonatal, and child lives saved Percentage reduction in deaths with 90% coverage - <30% Ethiopia Northern Nigeria 31 -60% >61% Ghana, Kenya Senegal, Uganda, Tanzania Cameroon South Africa Southern Nigeria TOTAL 903, 400 606, 000 310, 200 1, 819, 700 79% 90% 59% 78% Country specific lives saved and cost for: Births in facilities – achievable missed opportunities to save lives Outreach or community interventions – achievable increases (20%) For Ethiopia, Kenya, Nigeria, Uganda, Tanzania, Senegal, Cameroon, South Africa

MCHIP & Li. ST MCHIP & Li. ST

How Li. ST is being used at MCHIP § Strategic Planning for country workplans How Li. ST is being used at MCHIP § Strategic Planning for country workplans § Which interventions are necessary to reduce mortality? (maternal, neonatal, under-5) § Based on feasible targets, what potential reduction in mortality will our program have? Can counteract current emphasis on one-sizefits-all intervention packages, by suggesting which specific interventions are more likely to have an impact in different contexts 20

Helping to Reach MDG 4 in Zimbabwe: Under 5 Mortality Rate Zimbabwe Current Trend Helping to Reach MDG 4 in Zimbabwe: Under 5 Mortality Rate Zimbabwe Current Trend Zimbabwe MCHIP Package Zimbabwe 90% Maternal Health Coverage Implementation begins in 2010 Zimbabwe MDG 4 Target

Helping to Reach MDG 5 in Zimbabwe: Maternal Mortality Ratio Zimbabwe Current Trend Zimbabwe Helping to Reach MDG 5 in Zimbabwe: Maternal Mortality Ratio Zimbabwe Current Trend Zimbabwe MCHIP Package Zimbabwe 90% Maternal Health Coverage Zimbabwe MDG 5 Target MDG Goal for Maternal Mortality

Decreased Child Deaths in Zimbabwe Decreased Child Deaths in Zimbabwe

How Li. ST is being used at MCHIP con’t § Advocacy and Planning Intervention How Li. ST is being used at MCHIP con’t § Advocacy and Planning Intervention Most Recent Survey Target Coverage by 2015 Maternal Lives Newborn Lives Saved Cumulatively 2010 -2015 MATERNAL & NEWBORN Antenatal Care 47% 67% Skilled Birth Attendance 44% 64% Clean Practices & ENC (Home)* 3. 9% 24% Facility-Based Births 40. 1% 60% Essential Care for All Women & Newborns** 20. 1% 15% Be. MONC** (Essential Care +) 12. 0% 9% Ce. MONC** (Essential, Be. MONC +) 8. 0% 36% Combined Maternal/Newborn Interventions 0 100 70 2, 000 4, 000 24, 000 24

MCHIP Lessons Learned & Recommendations MCHIP Lessons Learned & Recommendations

What Li. ST Is, What Li. ST Isn’t Is Multi-cause mortality model Mathematic model What Li. ST Is, What Li. ST Isn’t Is Multi-cause mortality model Mathematic model Models coverage impacts Potential impact assessment National or sub-national planning tool § Discussion points § Evidence-based § Effective advocacy tool § § § 26 Isn’t Truth Probabilistic model Natural history model Detailed costing or planning tool § Bottlenecks, budgeting § Exhaustive § §

Food for Thought Maternal Health Intervention Assumptions: § Because of the much smaller numbers Food for Thought Maternal Health Intervention Assumptions: § Because of the much smaller numbers of maternal deaths & the continuing work to determine the impact that some interventions have on maternal survival, Li. ST may not be the best tool to weigh the relative value of different investments in maternal survival § MH interventions included in Li. ST are packages that are only effective in reducing mortality if all services are provided at quality

Food for Thought § It is often just as important to show the impact Food for Thought § It is often just as important to show the impact of scaling back interventions that already have high coverage levels (ie. Lives LOST due to rollback in coverage) § Particularly important for mature interventions (i. e. Immunization, Vit A coverage) § We do not want projections to inadvertently make the case for decreasing funding/coverage for these interventions

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