Transcript The Child Survival IMPACT Model: A quick start

ESTIMATING THE IMPACT OF
MATERNAL, NEONATAL AND
CHILD SURVIVAL INTERVENTIONS
Ingrid Friberg, PhD
The Lives Saved Tool - LiST
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The Lives Saved Tool
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A multi-cause model of mortality
Predict changes in
Under 5 and neonatal mortality rates and deaths
 Maternal mortality ratios and deaths
 Stillbirth rates and deaths
 Causes of death
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Using
Country specific health status
 Changes in child and maternal health intervention coverage levels
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i.e. ORS, facility delivery, etc.
Effect sizes of interventions based on the best available evidence
LiST
Beginnings:
Grew out of the “Bellagio” modeling exercise and the Lancet Child
Survival Series (2003). Added in neonatal, nutrition, and updated
information
Goals:
Promote evidence-based decision making
Aid in planning expansion of maternal, neonatal and child health
interventions
Objectives:
Estimate lives saved when introducing or scaling up key interventions
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General Framework
Demographic
estimates and
projections
UN Pop/Spectrum
Health Status
•Stunted, wasted
•Malaria prevalence
•Vit A deficiency
•Zinc deficiency
Number of
Child, Maternal
and Fetal
deaths
Intervention Coverage
Current
Target/Goal/Endline
*Change is critical*
Deaths averted
-By cause
-By intervention
Deaths by
Cause
WHO/UNICEF
Country estimates
Effectiveness
Estimates
Intervention Impact
Int1
Int2
Int3
C1 C2 C3 C4 …
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Stunting, Wasting, Breastfeeding
Which interventions were included?
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Proximate factors
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Work through health programs
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Not included: income, education and crowding, etc.
Water and sanitation are the exceptions
Feasible in a low income country
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Not distal
68 priority countries with highest MNCH mortality
Cause-specific evidence of effect
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Research studies or systematic reviews
Delphi method if research is impossible (i.e. CEmOC)
Updated frequently
IJE April 2010, BMC Public Health April 2011
Intervention Types
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Maternal, fetal, neonatal, child
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Periconceptional, antenatal, birth, immediate postnatal, child
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Preventive, curative
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Nutritional, vaccination, water/sanitation, treatment
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Risk factors: Cause-of-death specific
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Immediate, time-lagged
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External (family planning, AIDS), internal (all others)
Periconceptional Interventions
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(Family planning)
Folic acid supplementation or fortification
Safe abortion services
Post abortion case management
Ectopic pregnancy case management
Pregnancy Interventions
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Tetanus toxoid vaccination
IPTp – malaria prevention in pregnancy
Syphilis detection and treatment
Calcium supplementation
Multiple micronutrient supplementation
Balanced energy supplementation
Diabetes case management
Maternal malaria case management
MgSO4 – management of pre-eclampsia
Fetal growth restriction and management
(PMTCT)
Childbirth Care Interventions
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Clean birth practices
Immediate assessment and stimulation of the neonate
Labor and delivery management
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Neonatal resuscitation
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SBA at home or facility, BEmONC and CEmONC
At home or facility
Antenatal corticosteroids for preterm labor
Antibiotics for pPRoM
MgSO4 – for eclampsia
AMTSL – active management of the third stage of labor
Induction of labor for pregnancies 41+ weeks
Preventive Interventions
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Thermal care
Clean postnatal practices
Breastfeeding
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Complementary feeding
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Promotion
Behavior
Education only
Education and supplementation
Vitamin A for prevention
Zinc for prevention
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Insecticide treated materials
Improved water source
Water connection in the home
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latrine, toilet
Hand washing with soap
Hygienic disposal of children’s
stools
BCG vaccine
Polio vaccine
Pentavalent vaccine
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Improved sanitation
DPT, Hib, HepB
Pneumococcal vaccine
Rotavirus vaccine
Measles vaccine
Curative Interventions
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Maternal sepsis case management
Kangaroo mother care
Case management of serious neonatal illnesses
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Oral antibiotics
Injectable antibiotics
Full supportive care: oxygen, IV fluids, IV antibiotics
ORS for diarrhea
Antibiotics for dysentery
Zinc for treatment of diarrhea
Oral antibiotics for management of pneumonia
Vitamin A for measles treatment
Therapeutic feeding
Antimalarials
(Cotrimoxazole for HIV+ children)
(ART for children)
What’s NOT in the model?
Education
Assumption:
 Motivation
 Gender issues
 Economic status
Several of these factors are
 Emergencies (i.e. famine, flooding)
DISTAL
factors which MAY work
 Delivery mechanism
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as relates to total
population coverage
through
COVERAGE
Quality of care
changes…thus
MAY
already
be
 Effectiveness values, adjustments
in the model
 Only
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Other things not in LiST
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De-worming (yet)
IPTi (yet)
Breastfeeding initiation within 1 hour (yet)
Birth spacing benefit
Treatment of water in the home
Iron (or iron-folate) supplementation
Indoor air pollution
…
What LiST is, What LiST isn’t!
Is
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Multi-cause mortality model
Mathematic model
Models coverage impacts
Potential impact assessment
National or sub-national
prioritization tool
Discussion points
Evidence-based
Isn’t
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Truth
Probabilistic model
Natural history model
Detailed costing or
planning tool
Bottlenecks, budgeting
Exhaustive
DATA AND MODELING
Data Needs
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Country-Specific
 Population
data and trends
 Default:
UN Population Division 1950-2050 (DemProj)
 User entered (district) data
 Cause
of death structure
 Default:
WHO/UNICEF/CHERG (2008)
 User entered data
 Intervention
coverage
 Population
based data
 Default: DHS/MICS/JMP/WHO-UNICEF (closest to 2008)
 User entered data
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Global
 Intervention
 User
Effectiveness data
entered data
Stunting
Appropriate
Complementary
Feeding
IUGR
Zinc
Diarrhea
incidence
Complementary feeding education
and/or supplementation
Previous
Stunting
Malaria
Mortality
Antimalarials
Wasting
Stunting
ITN/IRS
Disease
Specific
Treatments
Disease
Specific
Preventions
Risk factors
Improved H2O source
within 30 minutes
Breast
Feeding
Promotion
Pneumococcal
vaccine
Hib vaccine
Hand washing
with soap
Breast Feeding
Improved sanitation
Diarrhea
incidence
Water connection
in the home
Hygienic disposal of
children’s stools
Stunting
Complementary feeding
education/supplementation
Pregnant women protected via IPT
or sleeping under an ITN
IUGR
Multiple micronutrient
supplementation
Balanced energy
supplementation
Zinc for prevention
Wasting
Therapeutic
feeding
Oral antibiotics for pneumonia
Pneumonia
Mortality
How are the models built?
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Preventions
Treatments
Risk factors
Multiple interventions?
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Two Preventions (or Risk Factors):
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Proportional impact by coverage/effect size
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Calculated on residual deaths
No double counting
Preventions and Treatments:
Enter prevention(s), then treatment(s)
 Deaths not already averted
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Some Limitations
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Data availability
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Data quality
Sensible scale up targets
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Feasible, acceptable, funds available
Interventions included in software
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If no baseline, can’t evaluate impact accurately
Some evaluated for one outcome, not others
Maternal
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No country specific cause of death yet; regional causes
No risk factors yet
Not yet vetted intervention impacts through CHERG and other
groups
LIST
“VALIDATION”
USES
Neonatal Package Modeling
ACSD Results
Modeling Mortality Rates and Equity
ITN studies
How can LiST be used?
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Planning, Evaluation, Research, Advocacy
Strategic planning
Which interventions are necessary to reduce mortality?
(maternal, neonatal, under-5)
 Will the targets reduce mortality as much as needed?
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Evaluation and intermediate-term follow-up
What is the impact of observed coverage changes?
 Evaluation of historic trends (i.e. multiple DHS/MICS surveys)
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Predict lives saved (past and future)
How many lives could be saved with full scale-up of proven
interventions in priority countries?
 How many deaths remain left after vaccination scale ups?
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How has LiST been used?
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Globally
Global Action Plan for Pneumonia
 ‘Impatient Optimist’ speech by Bill Gates
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Regionally
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ASADI, by Saving Newborn Lives
Country level
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Catalytic initiative: to guide planning and priority setting
(Malawi, Ghana, Niger)
 Ethiopia
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Sub-nationally
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CSHGP
DFID in Nigeria (PRRINN-MNCH)
Who has used LiST?
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Gates Foundation, GAVI
USAID, DFID, CIFF
MCHIP
Save the Children, Saving Newborn Lives, MSH
WHO (GAPP), UNICEF
CHAI
How NOT to use LiST
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As the correct answer
 It
depends on what you put in and what your goals are
 Also must consider cost, feasibility, accepability
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To suggest decreasing coverage of any interventions
 Mortality
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To suggest taking funds away from interventions
To suggest that things in LiST are “GOOD” while
everything else is “BAD”
 It
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has declined BECAUSE of those interventions
is based upon data availability unless otherwise stated
To decide HOW to do anything!!!
 That
is for the programmers to decide!
What can I get out of LiST?
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Number of deaths
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Mortality rates/ratios (NMR, U5MR, MMR, SBR)
Deaths averted,
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Total, by cause, by intervention, by age group
Intermediate outcomes
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Total, by cause, by age group
Stunting, wasting, breastfeeding
Displays
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Tables, graphs, pie charts
Single country, multiple scenarios within one country
Multiple countries, single or multiple scenarios
Future Directions for LiST
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Costing tie-ins
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Both a CHOICE based costing tool and MBB
Part of the new One Health Model
Yes, we will be adding in uncertainty
Improve the maternal model
A new tool for multi-country analyses
LiST Resources
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FREE
Web Links
 www.futuresinstitute.org
 www.healthpolicyinitiative.com/index.cfm?id=software&get
=Spectrum
 www.jhsph.edu/iip/list (join the listserv there)
 list.cherg.org
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Software + Manual Languages
 English,
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French, Spanish, Portuguese
Contact
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Ingrid Friberg - [email protected]