Re-envisioning Kangaroo Mother Care Implementation Through a Socioecological Model: Lessons From Malawi.

INTRODUCTION: Kangaroo mother care (KMC) is a critical strategy to care for preterm and low birth weight infants in resource-limited settings. Despite evidence of its effectiveness and low cost, coverage has remained low, largely due to sociocultural barriers. We aimed to better understand social norms and community perceptions of preterm infants and KMC (facility-initiated and community-continued) in Malawi, a country with a high preterm birth rate, to inform a pilot social and behavior change program. METHODS: In this qualitative study, we conducted 11 focus group discussions and 20 in-depth interviews. Participants were identified through purposive and snowball sampling and included pregnant women, parents engaged in KMC, health workers, community members, and religious leaders. Audio recordings were transcribed and translated into English. An inductive thematic analysis was applied. RESULTS: Our analysis revealed 3 key injunctive norms influencing KMC engagement in this setting: (1) a perception that although preterm infants are abnormal, they should still be cared for, (2) an understanding that men should provide for their families while women should care for their families, and (3) families and communities should support one another. These norms operated at the community, family, household, and individual levels. Community members enforced social norms but also offered social support. Family members supported KMC parents as well. Both KMC parents actively engaged in the practice; however, their interest in and ability to manage its demands were influenced by the prevailing social norms, their economic situation, family obligations, and the mother's health status. CONCLUSION: KMC efforts can be strengthened by incorporating context-specific actions to bolster social norms that align with KMC and shift those that discourage it. Activities must include a focus on the community and family levels to engender meaningful change at the household level.

Monitoring the implementation and scale-up of a life-saving intervention for preterm and small babies: Facility-based Kangaroo Mother Care.

BACKGROUND: Kangaroo mother care (KMC) is an evidence-based intervention with large protective effects on neonatal mortality and morbidity, especially among small babies. Despite the available evidence, KMC adoption, implementation and scale-up has lagged. The purpose of this paper is to inform current and future KMC implementation by identifying achievements and challenges in countries that are in the process of scaling up KMC. METHODS: We collected and analyzed information to track the status of facility-based KMC in countries identified by the KMC Acceleration Partnership. We assessed the status of the scale-up in six priority countries (Ethiopia, Malawi, Nigeria and Rwanda in Africa, and Bangladesh and India in Asia) for three periods: 2014 and prior, 2015-2017 and 2017-2019 across six strategic areas: national policy, country implementation, research, knowledge management, monitoring and evaluation and advocacy. We collected information through in-depth interviews with key participants, quantitative data extraction from the Demographic Health Survey and secondary data extraction from policies, briefs, program reports and other documents. RESULTS: Progress in terms of national policy and advocacy appeared to occur quite quickly and evenly across the six priority countries, despite being at different stages during the first assessment. In the areas of country implementation support and research, progress occurred more slowly and results were more variable across countries. It was noted that the number of health facilities offering KMC services increased in all six priority countries, but coverage of KMC was difficult to estimate, demonstrating the ongoing challenges in the area of monitoring and evaluation despite progress made in integrating KMC indicators into national health information systems in five countries. Among the six priority countries - Malawi and Bangladesh had fully achieved at least four the first time six conditions were introduced. CONCLUSIONS: We documented notable achievements in the dimensions of policy and country implementation across the six countries, which were likely driven by government engagement to prioritize newborn care services and the promotion of KMC as a core intervention for small babies. We noted challenges in critical areas such as ambulatory KMC, follow-up, and monitoring and evaluation. Addressing these gaps while securing funding to allocate human resources adequately, promoting acceptance of KMC for demand creation and facilitating the use of data for decision making will be vital to ensure effective coverage at scale.

Operationalising health systems thinking: a pathway to high effective coverage.

BACKGROUND: The global health community has recognised the importance of defining and measuring the effective coverage of health interventions and their implementation strength to monitor progress towards global mortality and morbidity targets. Existing health system models and frameworks guide thinking around these measurement areas; however, they fall short of adequately capturing the dynamic and multi-level relationships between different components of the health system. These relationships must be articulated for measurement and managed to effectively deliver health interventions of sufficient quality to achieve health impacts. Save the Children's Saving Newborn Lives programme and EnCompass LLC, its evaluation partner, developed and applied the Pathway to High Effective Coverage as a health systems thinking framework (hereafter referred to as the Pathway) in its strategic planning, monitoring and evaluation. METHODS: We used an iterative approach to develop, test and refine thinking around the Pathway. The initial framework was developed based on existing literature, then shared and vetted during consultations with global health thought leaders in maternal and newborn health. RESULTS: The Pathway is a robust health systems thinking framework that unpacks system, policy and point of intervention delivery factors, thus encouraging specific actions to address gaps in implementation and facilitate the achievement of high effective coverage. The Pathway includes six main components - (1) national readiness; (2) system structures; (3) management capacity; (4) implementation strength; (5) effective coverage; and (6) impact. Each component is comprised of specific elements reflecting the range of facility-, community- and home-based interventions. We describe applications of the Pathway and results for in-country strategic planning, monitoring of progress and implementation strength, and evaluation. CONCLUSIONS: The Pathway provides a cohesive health systems thinking framework that facilitates assessment and coordinated action to achieve high coverage and impact. Experiences of its application show its utility in guiding strategic planning and in more comprehensive and effective monitoring and evaluation as well as its potential adaptability for use in other health areas and sectors.

A national survey of private-sector outpatient care of sick infants and young children in Nepal.

BACKGROUND: Previous research has documented that across South Asia, as well as in some countries in Sub-Saharan Africa, the private sector is the primary source of outpatient care for sick infants and children and, in many settings, informal providers play a bigger role than credentialed health professionals (particularly for the poorer segments of the population). This is the case in Nepal. This study sought to characterize medicine shop-based service providers in rural areas and small urban centers in Nepal, their role in the care and treatment of sick infants and children (with a particular focus on infants aged < 2 months), and the quality of the care provided. A secondary objective was to characterize availability and quality of such care provided by physicians in these settings. METHODS: A nationally representative sample of medicine shops was drawn, in rural settings and small urban centers in Nepal, from 25 of the 75 districts in Nepal, using multi-stage cluster methodology, with a final sample of 501 shops and 82 physician-run clinics. Face-to-face interviews were conducted. RESULTS: Most medicine shops outside urban areas were not registered with the Department of Drug Administration (DDA). Most functioned as de facto clinics, with credentialed paramedical workers (having 2-3 years of training) diagnosing patients and making treatment decisions. Such a role falls outside their formally sanctioned scope of practice. Quality of care problems were identified among medicine shop-based providers and physicians, including over-use of antibiotics for treating diarrhea, inaccurate weighing technique to determine antibiotic dose, and inappropriate use of injectable steroids for treating potentially severe infections in young infants. CONCLUSIONS: Medicine shop-based practitioners in Nepal represent a particular type of informal provider; although most have recognized paramedical credentials, they offer services falling outside their formal scope of practice. Nevertheless, given the large proportion of the population served by these practitioners, engagement to strengthen quality of care by these providers and referral to the formal health sector is warranted.

Feasibility of implementing the World Health Organization case management guideline for possible serious bacterial infection among young infants in Ntcheu district, Malawi.

BACKGROUND: Neonatal sepsis is a leading cause of mortality, yet the recommended inpatient treatment options are inaccessible to most families in low-income settings. In 2015, the World Health Organization released a guideline for outpatient treatment of young infants (0-59 days of age) with possible serious bacterial infection (PSBI) with simplified antibiotic regimens when referral was not feasible. If implemented widely, this guideline could prevent many deaths. Our implementation research evaluated the feasibility and acceptability of implementing the WHO guideline through the existing health system in Malawi. METHODS: A prospective cohort study was conducted in 12 first-level health facilities in Ntcheu district. Trained health workers identified and treated young infants with PSBI signs with injection gentamicin for 2 days and oral amoxicillin for 7 days, whereas those with only fast breathing were treated with oral amoxicillin for 7 days. Health Surveillance Assistants (HSAs) were trained to promote care-seeking and to conduct home visits on day 3 and 6 to assess infants under treatment, encourage treatment adherence and remind the caregiver to return for facility follow up. Infants receiving outpatient treatment were followed up at health facility on day 4 and 8. The primary outcome was proportion of outpatient cases completing treatment per protocol. FINDINGS: A total of 358 infants received outpatient treatment (202 clinical severe infection, 156 only fast breathing) from February to September 2017. Of these, 92.7% (332/358) met criteria for treatment completion and 88.8% (318/358) completed the day 4 follow-up. Twelve (3.4%) young infants clinically failed treatment with no reported deaths in those treated at outpatient level. This treatment failure rate was lower than those reported for the simplified regimens tested in the SATT (8-10%) and AFRINEST (5-8%) equivalency trials. More than half of infants (58.1%; 208/358) received HSA follow-up visits on days 3 and 6. CONCLUSION: Study results demonstrate the feasibility of outpatient treatment for sick young infants when referral is not feasible in Malawi, which will inform scale-up in other parts of Malawi and countries with similar health system constraints.

Improving Skin-to-Skin Practice for babies in Kangaroo Mother Care in Malawi through the use of a customized baby wrap: A randomized control trial.

BACKGROUND: Complications of prematurity are a leading cause of newborn death in Malawi. Despite early adoption of Kangaroo mother care (KMC), coverage remains low and women have expressed challenges in using the traditional wrapper-chitenje. In 2016, a study was conducted to evaluate the acceptability and effectiveness of a customized KMC wrap in improving adherence to KMC practices among mothers. METHODS: Mother-baby dyads (301) were randomized to receive either a customized CarePlus Wrap developed by Lærdal Global Health or a traditional chitenje. Enrolled mother-baby dyads were assessed in the KMC ward at 2-3 days after of admission, and then again at 7-15 days post-discharge. Topics covered included skin-to-skin practices, breastfeeding, perceptions of the wrap, and family/community support. Chi square tests were used to assess associations between wrap type and KMC practices. The study received ethics approval. RESULTS: This study found that a customized KMC wrap is highly acceptable to women and improved skin-to-skin practices in facility-based KMC: 44% of mothers using a customized wrap reported 20 or more hours per day, compared to 33% of mothers using the traditional chitenje. Women using the customized wrap reported being comfortable in keeping the baby in skin-to-skin position more often than women using the chitenje (96% vs. 71%), and they were able to tie on the wrap themselves (86% vs. 10%). At the time of discharge from KMC, more women who used the customized wrap were satisfied with the wrap than those who used the traditional chitenje (94% vs. 56%). The customized wrap did not appear to impact other newborn practices, such as breastfeeding. CONCLUSIONS: This study provides evidence that a customized KMC wrap is highly acceptable to mothers, and it can contribute to better skin-to-skin practices. Use of a customized wrap may be one mechanism to support mothers in practicing KMC and skin-to-skin contact in addition to other interventions.

Achievements and challenges of implementation in a mature iCCM programme: Malawi case study.

BACKGROUND: Malawi has a mature integrated community case management (iCCM) programme that is led by the Ministry of Health (MOH) but that still relies on donor support. From 2013 until 2017, under the Rapid Access Expansion (RAcE) programme, the World Health Organization supported the MOH to expand and strengthen iCCM services in four districts. This paper examines Malawi's iCCM programme performance and implementation strength in RAcE districts to further strengthen the broader programme. METHODS: Baseline and endline household surveys were conducted in iCCM-eligible areas of RAcE districts. Primary caregivers of recently-sick children under five were interviewed to assess changes in care-seeking and treatment over the project period. Health surveillance assistants (HSAs) were surveyed at endline to assess iCCM implementation strength. RESULTS: Care-seeking from HSAs and treatment of fever improved over the project period. At endline, however, less than half of sick children were brought to an HSA, many caregivers reported a preference for providers other than HSAs, and perceptions of HSAs as trusted providers of high-quality, convenient care had decreased. HSA supervision and mentorship were below MOH targets. Stockouts of malaria medicines were associated with decreased care-seeking from HSAs. Thirty percent of clusters had limited or no access to iCCM (no HSA or an HSA providing iCCM services less than 2 days per week); 50% had moderate access (an HSA providing iCCM services 2 to 4 days per week; and 20% had high access (a resident HSA providing iCCM services 5 or more days per week). Moderate access to iCCM was associated with increased care-seeking from HSAs, increased treatment by HSAs, and more positive perceptions of HSAs compared to areas with limited or no access. Areas with high access to iCCM did not show further improvements above areas with moderate access. CONCLUSIONS: Availability of well-equipped and supported HSAs is critical to the provision of iCCM services. Additional qualitative research is needed to examine challenges and to inform potential solutions. Malawi's mature iCCM programme has a strong foundation but can be improved to strengthen the continuity of care from communities to facilities and to ultimately improve child health outcomes.

Home visits by community health workers for pregnant mothers and newborns: coverage plateau in Malawi.

BACKGROUND: Home visits by community health workers (CHWs) during pregnancy and soon after delivery are recommended to improve newborn survival. However, as the roles of CHWs expand, there are concerns regarding the capacity of community health systems to deliver high effective coverage of home visits. The WHO's Rapid Access Expansion (RAcE) program supported the Malawi Ministry of Health to align their Community-Based Maternal and Newborn Care (CBMNC) package with the latest WHO guidelines and to implement and evaluate the feasibility and coverage of home visits in Ntcheu district. METHODS: A population-based survey of 150 households in Ntcheu district was conducted in July-August 2016 after approximately 10 months of CBMNC implementation. Thirty clusters were selected proportional-to-size using the most recent census. In selected clusters, five households with mothers of children under six months of age were randomly selected for interview. The Health Surveillance Assistants (HSAs) providing community-based services to the same clusters were purposively selected for a structured interview and register review. RESULTS: Less than one third of pregnant women (30.7%; 95% confidence interval CI = 21.7%-41.5%) received a home visit during pregnancy and only 20.7% (95% CI = 13.0%-29.4%) received the recommended two visits. Coverage of postnatal visits was even lower: 11.4% (95%CI = 6.8%-18.5%) of mothers and newborns received a visit within three days of delivery and 20.7% (95%CI = 12.7%-32.0%) received a visit within the first eight days. Reaching newborns soon after delivery requires timely participation of the family and/or health facility staff to notify the HSA - yet only 42.9% (95% CI = 33.4%-52.9%) of mothers reported that the HSA was informed of the delivery. Coverage of postnatal home visits among those who informed the HSA was significantly higher than among those in which the HSA was not informed (46.7% compared to 1.3%; P = 0.00). Most HSAs had the necessary equipment and supplies and were active in CBMNC: 83.9% (95% CI = 70.2%-97.6%) of HSAs had pregnancy home visits and 77.4% (95% CI = 61.8%-93.0%) had postnatal home visits documented in their registers for the previous three months. CONCLUSIONS: We found low coverage of home visits during pregnancy and soon after delivery in a well-supported program delivery environment. Most HSAs were conducting home visits, but not at the level needed to reach high coverage. These findings were similar to previous studies, calling into question the feasibility of the current visitation schedule. It is time to re-align the CBMNC package with what the existing platform can deliver and identify strategies to better support HSAs to implement home visits to those who would benefit most.

Service readiness for inpatient care of small and sick newborns: what do we need and what can we measure now?

BACKGROUND: Each year an estimated 2.6 million newborns die, mainly from complications of prematurity, neonatal infections, and intrapartum events. Reducing these deaths requires high coverage of good quality care at birth, and inpatient care for small and sick newborns. In low- and middle-income countries, standardised measurement of the readiness of facilities to provide emergency obstetric care has improved tracking of readiness to provide care at birth in recent years. However, the focus has been mainly on obstetric care; service readiness for providing inpatient care of small and sick newborns is still not consistently measured or tracked. METHODS: We reviewed existing international guidelines and resources to create a matrix of the structural characteristics (infrastructure, equipment, drugs, providers and guidelines) for service readiness to deliver a package of inpatient care interventions for small and sick newborns. To identify gaps in existing measurement systems, we reviewed three multi-country health facility survey tools (the Service Availability and Readiness Assessment, the Service Provision Assessment and the Emergency Obstetric and Newborn Care Assessment) against our service readiness matrix. FINDINGS: For service readiness to provide inpatient care for small and sick newborns, our matrix detailed over 600 structural characteristics. Our review of the SPA, the SARA and the EmONC assessment tools identified several measurement omissions to capture information on key intervention areas, such as thermoregulation, feeding and respiratory support, treatment of specific complications (seizures, jaundice), and screening and follow up services, as well as specialised staff and service infrastructure. CONCLUSIONS: Our review delineates the required inputs to ensure readiness to provide inpatient care for small and sick newborns. Based on these findings, we detail where questions need to be added to existing tools and describe how measurement systems can be adapted to reflect small and sick newborns interventions. Such work can inform investments in health systems to end preventable newborn death and disability as part of the Every Newborn Action Plan.

Starting the conversation: community perspectives on preterm birth and kangaroo mother care in southern Malawi.

BACKGROUND: Despite introduction of Kangaroo Mother Care (KMC) in Malawi over a decade ago, preterm birth remains the leading cause of neonatal mortality. Although KMC is initiated in the health care facility, robust community follow-up is critical for survival and optimal development of preterm and low birth weight infants post-discharge. The objective of this qualitative study was to gain insight into community and health worker understanding, attitudes, beliefs and practices around preterm and low birth weight babies and KMC in Malawi. METHODS: A total of 152 participants were interviewed in two districts in southern Malawi, Machinga and Thyolo, in April 2015. Focus group discussions (groups = 11, n = 132) were conducted with pregnant women, community members and women who have practiced KMC. In-depth interviews (n = 20) were conducted with fathers who have practiced KMC, community and religious leaders, and health workers. Purposive and snowball sampling were employed to identify participants. Thematic content analysis was conducted. FINDINGS: KMC mothers and fathers only learned about KMC and care for preterm newborns after delivery of a child in need of this care. Men typically were not included in KMC counseling due to societal gender roles. Health facilities were the main source of information on KMC, however informal networks among women provided some degree of knowledge exchange. Community leaders were regarded as major facilitators of health information, conveners, key influencers, and policy-makers. Religious leaders were regarded as advocates and emotional support for families with preterm infants. Finally, while many participants initially had negative feelings towards preterm births and KMC, the large majority saw a shift in their perceptions through health counseling, peer modeling, and personal success with KMC. CONCLUSIONS: The findings offer several opportunities to improve KMC implementation including 1) earlier introduction of KMC to pregnant women and their families that are at-risk for preterm birth, 2) greater involvement of men in KMC counselling, practice and care for preterm infants, and 3) strengthening and defining partnerships with community and religious leaders. Finally, as parental perceptions of preterm infants and KMC improved with successful KMC practice, it is hopeful that KMC itself can positively affect social norms surrounding preterm infants, leading to a virtuous cycle of improved perceptions of preterm infants and increased uptake of KMC.

Readiness of hospitals to provide Kangaroo Mother Care (KMC) and documentation of KMC service delivery: Analysis of Malawi 2014 Emergency Obstetric and Newborn Care (EmONC) survey data.

BACKGROUND: Malawi introduced Kangaroo Mother Care (KMC) in 1999 as part of its efforts to address newborn morbidity and mortality and has continued to expand KMC services across the country. Yet, data on availability of KMC services and routine service provision are limited. METHODS: Data from the 2014 Emergency Obstetric Newborn Care (EmONC) survey, which was a census of all 87 hospitals in Malawi, were analyzed. The WHO service availability and readiness domains were used to generate indicators for KMC service readiness and an additional domain for documentation of KMC services was included. Levels of KMC service delivery were quantified using data extracted from a 12-month register review and a KMC initiation rate was calculated for each facility by dividing the reported number of babies initiated on KMC by the number of live births at facility. We defined three levels of KMC readiness and two levels of KMC operational status. RESULTS: 79% of hospitals (69/87) reported providing inpatient KMC services. More than half of the hospitals (62%; 54/87) met the most basic definition of readiness (staff, space for KMC and functional weighing scale) and 35% (30/87) met an expanded definition of readiness (guidelines, staff, space, scale and register in use). Only 15% (13/87) of hospitals had all KMC tracer items. Less than half of the hospitals (43%; 37/87) met criteria for KMC operational status at minimum levels (≥1/100 live births), and just 16% (14/87) met criteria for KMC operational status at routine levels (≥5/100 live births). CONCLUSIONS: Our study found large differences between reported levels of KMC services and documented levels of KMC readiness and service provision among hospitals in Malawi. It is recommended that facility assessments of services such as KMC include record reviews to better estimate service availability and delivery. Further efforts to strengthen the capacity of Malawian hospitals to deliver KMC are needed.

Using Data to Improve Programs: Assessment of a Data Quality and Use Intervention Package for Integrated Community Case Management in Malawi.

Health Surveillance Assistants (HSAs) have been providing integrated community case management (iCCM) for sick children in Malawi since 2008. HSAs report monthly iCCM program data but, at the time of this study, little of it was being used for service improvement. Additionally, HSAs and facility health workers did not have the tools to compile and visualize the data they collected to make evidence-based program decisions. From 2012 to 2013, we worked with Ministry of Health staff and partners to develop and pilot a program in Dowa and Kasungu districts to improve data quality and use at the health worker level. We developed and distributed wall chart templates to display and visualize data, provided training to 426 HSAs and supervisors on data analysis using the templates, and engaged health workers in program improvement plans as part of a data quality and use (DQU) package. We assessed the package through baseline and endline surveys of the HSAs and facility and district staff in the study areas, focusing specifically on availability of reporting forms, completeness of the forms, and consistency of the data between different levels of the health system as measured through results verification ratio (RVR). We found evidence of significant improvements in reporting consistency for suspected pneumonia illness (from overreporting cases at baseline [RVR=0.82] to no reporting inconsistency at endline [RVR=1.0]; P=.02). Other non-significant improvements were measured for fever illness and gender of the patient. Use of the data-display wall charts was high; almost all HSAs and three-fourths of the health facilities had completed all months since January 2013. Some participants reported the wall charts helped them use data for program improvement, such as to inform community health education activities and to better track stock-outs. Since this study, the DQU package has been scaled up in Malawi and expanded to 2 other countries. Unfortunately, without the sustained support and supervision provided in this project, use of the tools in the Malawi scale-up is lower than during the pilot period. Nevertheless, this pilot project shows community and facility health workers can use data to improve programs at the local level given the opportunity to access and visualize the data along with supervision support.

Consensus-based approach to develop a measurement framework and identify a core set of indicators to track implementation and progress towards effective coverage of facility-based Kangaroo Mother Care.

BACKGROUND: As efforts to scale up the delivery of Kangaroo Mother Care (KMC) in facilities are increasing, a standardized approach to measure implementation and progress towards effective coverage is needed. Here, we describe a consensus-based approach to develop a measurement framework and identify a core set of indicators for monitoring facility-based KMC that would be feasible to measure within existing systems. METHODS: The KMC measurement framework and core list of indicators were developed through: 1) scoping exercise to identify potential indicators through literature review and requests from researchers and program implementers; and 2) face-to-face consultations with KMC and measurement experts working at country and global levels to review candidate indicators and finalize selection and definitions. RESULTS: The KMC measurement framework includes two main components: 1) service readiness, based on the WHO building blocks framework; and 2) service delivery action sequence covering identification, service initiation, continuation to discharge, and follow-up to graduation. Consensus was reached on 10 core indicators for KMC, which were organized according to the measurement framework. We identified 4 service readiness indicators, capturing national level policy for KMC, availability of KMC indicators in HMIS, costed operational plans for KMC and availability of KMC services at health facilities with inpatient maternity services. Six indicators were defined for service delivery, including weighing of babies at birth, identification of those ≤2000 g, initiation of facility-based KMC, monitoring the quality of KMC, status of babies at discharge from the facility and levels of follow-up (according to country-specific protocol). CONCLUSIONS: These core KMC indicators, identified with input from a wide range of global and country-level KMC and measurement experts, can aid efforts to strengthen monitoring systems and facilitate global tracking of KMC implementation. As data collection systems advance, we encourage program managers and evaluators to document their experiences using this framework to measure progress and allow indicator refinement, with the overall aim of working towards sustainable, country-led data systems.

Malawi three district evaluation: Community-based maternal and newborn care economic analysis.

Malawi is one of few low-income countries in sub-Saharan Africa to have met the fourth Millennium Development Goal for child survival (MDG 4). To accelerate progress towards MDGs, the Malawi Ministry of Health's Reproductive Health Unit - in partnership with Save the Children, UNICEF and others - implemented a Community Based Maternal and Newborn Care (CBMNC) package, integrated within the existing community-based system. Multi-purpose Health Surveillance Assistants (HSAs) already employed by the local government were trained to conduct five core home visits. The additional financial costs, including donated items, incurred by the CBMNC package were analysed from the perspective of the provider. The coverage level of HSA home visits (35%) was lower than expected: mothers received an average of 2.8 visits rather than the programme target of five, or the more reasonable target of four given the number of women who would go away from the programme area to deliver. Two were home pregnancy and less than one, postnatal, reflecting greater challenges for the tight time window to achieve postnatal home visits. As a proportion of a 40 hour working week, CBMNC related activities represented an average of 13% of the HSA work week. Modelling for 95% coverage in a population of 100,000, the same number of HSAs could achieve this high coverage and financial programme cost could remain the same. The cost per mother visited would be US$6.6, or US$1.6 per home visit. The financial cost of universal coverage in Malawi would stand at 1.3% of public health expenditure if the programme is rolled out across the country. Higher coverage would increase efficiency of financial investment as well as achieve greater effectiveness.

Multi-country analysis of the cost of community health workers kits and commodities for community-based maternal and newborn care.

Community-based maternal and newborn care with home visits by community health workers (CHWs) are recommended by WHO to complement facility-based care. As part of multi-country economic and systems analyses, we aimed to compare the content and financial costs associated with equipping CHWs or 'home visit kits' from seven studies in Bolivia, Ethiopia, Ghana, Malawi, South Africa, Tanzania and Uganda. We estimated the equivalent annual costs (EACs) of home visit kits per CHW in constant 2015 USD. We estimated EAC at scale in a population of 100 000 assuming four home visits per mother during the pregnancy and postnatal period. All seven packages were designed for health promotion; six included clinical assessments and one included curative care. The items used by CHWs differed between countries, even for the same task. The EAC per home visit kit ranged from $15 in Tanzania to $116 in South Africa. For health promotion and preventive care, between 82 and 100% of the cost of CHW commodities did not vary with the number of home visits conducted; however, in Ethiopia, the majority of EAC associated with curative care varied with the number of visits conducted. The EAC of equipping CHWs to meet the needs of 95% of expectant mothers in a catchment area of 100 000 people was highest in Bolivia, $40 260 for 633 CHWs, due to mothers being in hard-to-reach areas with CHW conducting few visits per year per, and lowest in Tanzania ($2693 for 172 CHWs), due to the greater number of CHW visits per week and lower EAC of items. To inform and ensure sustainable implementation at scale, national discussions regarding the cadre of CHWs and their workload should also consider carefully the composition and cost of equipping CHWs to carry out their work effectively and efficiently.

Integrated community case management (iCCM) of childhood infection saves lives in hard-to-reach communities in Nicaragua.

OBJECTIVE: To describe Nicaragua's integrated community case management (iCCM) program for hard-to-reach, rural communities and to evaluate its impact using monitoring data, including annual, census-based infant mortality data. METHOD: This observational study measured the strength of iCCM implementation and estimated trends in infant mortality during 2007-2013 in 120 remote Nicaraguan communities where brigadistas ("health brigadiers") offered iCCM services to children 2-59 months old. The study used program monitoring data from brigadistas' registers and supervision checklists, and derived mortality data from annual censuses conducted by the Ministry of Health. The mortality ratio (infant deaths over number of children alive in the under-1-year age group) was calculated and point estimates and exact binomial confidence intervals (CIs) were reported. RESULTS: Monitoring data revealed strong implementation of iCCM over the study period, with medicine availability, completeness of recording, and correct classification always exceeding 80%. Treatments provided by brigadistas for pneumonia and diarrhea closely tracked expected cases and caregivers consistently sought treatment more frequently from brigadistas than from health facilities. The infant mortality ratio decreased more in iCCM areas compared to the non-iCCM areas. Statistically significant reduction ranged from 52% in 2010 (mortality rate ratio 0.48; 95% CI: 0.25-0.92) to 59% in 2013 (mortality rate ratio 0.41; 95% CI: 0.21-0.81). CONCLUSIONS: The iCCM has been found to be an effective and feasible strategy to save infant lives in hard-to-reach communities in Nicaragua. The impact was likely mediated by increased use of curative interventions, made accessible and available at the community level, and delivered through high-quality services, by brigadistas.

Contribution of community health workers to improving access to timely and appropriate case management of childhood fever in Mozambique.

BACKGROUND: Large scale evaluations in several settings have demonstrated that lay community health workers can be trained to provide quality case management of childhood illnesses. In 2010, Mozambique introduced the integrated community case management (iCCM) strategy to reach children in remote areas with care provided through Agentes Polivalentes Elementares (APEs). We assessed the contribution of the program to improved care-seeking and appropriate treatment of childhood febrile illness in Nampula Province. METHODS: We used a post-test quasi-experimental design with three intervention and one comparison districts to compare access and appropriateness of care for sick children in Nampula province. We carried out a household survey in the study districts to measure levels of care-seeking and treatment of childhood fever after approximately two years of full implementation of the iCCM program in the intervention districts. We also assessed consistency of care with standard case management protocols comparing children receiving care from (APEs) to those receiving care from first-level health facilities. RESULTS: A total of 773 children 6-59 months with fever in the last two weeks were included in the study. In iCCM served areas, APEs were the predominant source of care and treatment; 87.1% (95% confidence interval CI 80.8-93.4) of children 6-59 months with fever who sought care were taken first to an APE and APEs accounted for 86.2% (95% CI 79.7-92.7) of all first-line antimalarial treatments. Public health facilities were the leading source of care in comparison areas, providing care to 86.1% (95% CI 79.0-93.3) of children with fever taken for care outside the home. Timeliness of treatment was significantly better in intervention areas, where 63.9% (95% CI 54.4-73.3) of children received treatment within 24 hours of symptom onset compared to 37.5% (95% CI 31.1-43.9) in comparison areas. Children taken first to an APE were more likely to receive a rapid diagnostic test (RDT) (68.1%; 95% CI 57.2-79.0) and to have their respiratory rate assessed (60.0%; 95% CI 45.4-74.6) compared to children taken to health facilities (41.4%; 95% CI33.7-49.2 and 19.4%; 95% CI 8.4-30.5, respectively). Overall, 61.3% (95% CI 51.5-71.0) of children with fever receiving care from APEs received the correct drug within 24 hours and for the correct duration compared to 26.0% (95% CI 18.2-33.9) of those receiving care from health facilities. CONCLUSION: iCCM contributed to improved timely and appropriate treatment for fever for children living far from facilities. Trained, supplied and supervised APEs provided care consistent with iCCM protocols and performed significantly better than first level facilities on most measures of adherence to case management protocols. These findings reinforce the need for comprehensive efforts to strengthen the health system in Mozambique to enable reliable support for quality of case management of childhood illness at both health facility and community levels.

Integrated community case management (iCCM) of childhood infection saves lives in hard-to-reach communities in Nicaragua / La atención integrada de las infecciones infantiles en la comunidad salva vidas en las comunidades de difícil acceso de Nicaragua / O manejo integrado de casos na comunidade (iCCM) aplicado às infecções infantis salva vidas em comunidades de difícil acesso na Nicarágua

Objective. To describe Nicaragua’s integrated community case management (iCCM) program for hard-to-reach, rural communities and to evaluate its impact using monitoring data, including annual, census-based infant mortality data. Method. This observational study measured the strength of iCCM implementation and estimated trends in infant mortality during 2007–2013 in 120 remote Nicaraguan communities where brigadistas (“health brigadiers”) offered iCCM services to children 2–59 months old. The study used program monitoring data from brigadistas’ registers and supervision checklists, and derived mortality data from annual censuses conducted by the Ministry of Health. The mortality ratio (infant deaths over number of children alive in the under-1-year age group) was calculated and point estimates and exact binomial confidence intervals (CIs) were reported. Results. Monitoring data revealed strong implementation of iCCM over the study period, with medicine availability, completeness of recording, and correct classification always exceeding 80%. Treatments provided by brigadistas for pneumonia and diarrhea closely tracked expected cases and caregivers consistently sought treatment more frequently from brigadistas than from health facilities. The infant mortality ratio decreased more in iCCM areas compared to the non-iCCM areas. Statistically significant reduction ranged from 52% in 2010 (mortality rate ratio 0.48; 95% CI: 0.25–0.92) to 59% in 2013 (mortality rate ratio 0.41; 95% CI: 0.21–0.81). Conclusions. The iCCM has been found to be an effective and feasible strategy to save infant lives in hard-to-reach communities in Nicaragua. The impact was likely mediated by increased use of curative interventions, made accessible and available at the community level, and delivered through high-quality services, by brigadistas.

Objetivo. Describir el programa nicaragüense de atención integrada en la comunidad destinado a las comunidades rurales de difícil acceso y evaluar sus efectos a partir de los datos de seguimiento, como los datos censales anuales sobre la mortalidad infantil (menores de 1 año). Método. Este estudio de observación tuvo como objetivo valorar la ejecución de la atención integrada en la comunidad y medir las tendencias de la mortalidad infantil (menores de 1 año) entre el 2007 y el 2013 en 120 comunidades nicaragüenses remotas donde los brigadistas brindan servicios de atención integrada en la comunidad a niños de 2 a 59 meses. El estudio se valió de datos programáticos de seguimiento obtenidos de los registros y las listas de verificación utilizadas para la supervisión de los brigadistas, así como datos de mortalidad derivados de los censos anuales realizados por el Ministerio de Salud. Se calculó la razón de mortalidad (defunciones de lactantes por cantidad de menores de un año vivos) y se informaron estimaciones puntuales e intervalos de confianza binomiales exactos. Resultados. Los datos de seguimiento mostraron una ejecución sólida del programa de atención integrada en la comunidad en el período del estudio, dado que la disponibilidad de medicamentos, los registros completos y la clasificación correcta siempre superaron el 80%. Como parte del tratamiento proporcionado contra la neumonía y la diarrea, los brigadistas llevaron a cabo un seguimiento minucioso de los casos previstos y los cuidadores solicitaron tratamiento de los brigadistas con más frecuencia que de los establecimientos de salud. La razón de mortalidad infantil (menores de 1 año) disminuyó más en las zonas atendidas por el programa que en aquellas no atendidas. Se observó una disminución estadísticamente significativa del 52% en el 2010 (razón de la tasa de mortalidad 0,48; IC del 95%: 8%-75%) al 59% en el 2013 (razón de la tasa de mortalidad 0,41; IC del 95%: 19%-79%). Conclusiones. El programa de atención integrada en la comunidad es una estrategia eficaz y factible para salvar la vida de los lactantes en las comunidades de difícil acceso de Nicaragua. Estos efectos probablemente estuvieron mediados por la mayor prestación de intervenciones curativas, que estuvieron accesibles y disponibles en el ámbito de la comunidad, y fueron brindadas por los brigadistas por medio de servicios de buena calidad.

Objetivo. Descrever o programa de manejo integrado de casos na comunidade (iCCM) para comunidades rurais e de difícil acesso na Nicarágua e avaliar seu impacto usando dados de monitoramento, inclusive dados censitários anuais de mortalidade infantil. Método. Este estudo observacional avaliou o nível de implementação da estratégia iCCM e calculou tendências de mortalidade infantil nos anos 2007-2013 em 120 comunidades remotas da Nicarágua onde “brigadistas de saúde” prestam serviços de iCCM para crianças de 2 a 59 meses de idade. Foram utilizados dados de monitoramento obtidos dos cadastros e checklists de supervisão de brigadistas e dados de mortalidade obtidos dos censos anuais realizados pelo Ministério da Saúde. Foi calculado o coeficiente de mortalidade infantil (número de óbitos infantis dividido pelo número de crianças menores de 1 ano vivas), além de estimativas pontuais e intervalos de confiança (IC) binomiais exatos. Resultados. Os dados de monitoramento evidenciaram forte implementação da estratégia iCCM durante o período de estudo; a disponibilidade de medicamentos, a integralidade dos registros e a classificação correta sempre excederam 80%. O tratamento da pneumonia e da diarreia por brigadistas acompanhou de perto o número de casos esperado, e os responsáveis pelas crianças sistematicamente buscaram tratamento com maior frequência junto aos brigadistas do que nos serviços de saúde. O coeficiente de mortalidade infantil diminuiu mais nas áreas com iCCM do que nas áreas sem iCCM. A redução foi estatisticamente significante, variando de 52% em 2010 (razão de taxa de mortalidade: 0,48; IC95%: 8%–75%) a 59% em 2013 (razão de taxa de mortalidade: 0,41; IC95%: 19%–79%). Conclusões. Constatou-se que a iCCM é uma estratégia eficaz e viável para salvar vidas de crianças em comunidades de difícil acesso na Nicarágua. O impacto provavelmente foi mediado pelo aumento do uso de intervenções resolutivas, disponibilizadas de maneira acessível no âmbito da comunidade, através do serviço qualificado prestado pelos brigadistas.

Does health facility service environment matter for the receipt of essential newborn care? Linking health facility and household survey data in Malawi.

BACKGROUND: Health facility service environment is an important factor for newborns survival and well-being in general and in particular in high mortality settings such as Malawi where despite high coverage of essential interventions, neonatal mortality remains high. The aim of this study is to assess whether the quality of the health service environment at birth is associated with quality of care received by the newborn. METHODS: We used data from the Malawi Millennium Development Goals Endline household survey conducted as part of MICS survey program and Service Provision Assessment Survey carried out in 2014. The analysis is based on 6218 facility births that occurred during the past 2 years. Descriptive statistics, bivariate and multivariate random effect models are used to assess the association of health facility service readiness score for normal deliveries and newborn care with newborns receiving appropriate newborn care, defined for this analysis as receiving 5 out of 6 recommended interventions during the first 2 days after birth. RESULTS: Newborns in districts with top facility service readiness score have 1.5 higher odds of receiving appropriate newborn care (adjusted odds ratio (aOR) = 1.52, 95% confidence interval CI = 1.19-1.95, P = 0.001), as compared to newborns in districts with a lower facility score after adjusting for potential confounders. Newborns in the Northern region were two times more likely to receive 5 newborn care interventions as compared to newborns in the Southern region (aOR = 2.06, 95% CI = 1.50-2.83, P < 0.001). Living in urban or rural areas did not have an impact on receiving appropriate newborn care. CONCLUSIONS: There is need to increase the level of service readiness across all facilities, so that all newborns irrespective of the health facility, district or region of delivery are able to receive all recommended essential interventions. Investments in health systems in Malawi should concentrate on increasing training and availability of health staff in facilities that offer normal delivery and newborn care services at all levels in the country.

Integrated community case management (iCCM) of childhood infection saves lives in hard-to-reach communities in Nicaragua / La atención integrada de las infecciones infantiles en la comunidad salva vidas en las comunidades de difícil acceso de Nicaragua / O manejo integrado de casos na comunidade (iCCM) aplicado às infecções infantis salva vidas em comunidades de difícil acesso na Nicarágua

ABSTRACT Objective To describe Nicaragua’s integrated community case management (iCCM) program for hard-to-reach, rural communities and to evaluate its impact using monitoring data, including annual, census-based infant mortality data. Method This observational study measured the strength of iCCM implementation and estimated trends in infant mortality during 2007–2013 in 120 remote Nicaraguan communities where brigadistas (“health brigadiers”) offered iCCM services to children 2–59 months old. The study used program monitoring data from brigadistas’ registers and supervision checklists, and derived mortality data from annual censuses conducted by the Ministry of Health. The mortality ratio (infant deaths over number of children alive in the under-1-year age group) was calculated and point estimates and exact binomial confidence intervals (CIs) were reported. Results Monitoring data revealed strong implementation of iCCM over the study period, with medicine availability, completeness of recording, and correct classification always exceeding 80%. Treatments provided by brigadistas for pneumonia and diarrhea closely tracked expected cases and caregivers consistently sought treatment more frequently from brigadistas than from health facilities. The infant mortality ratio decreased more in iCCM areas compared to the non-iCCM areas. Statistically significant reduction ranged from 52% in 2010 (mortality rate ratio 0.48; 95% CI: 0.25–0.92) to 59% in 2013 (mortality rate ratio 0.41; 95% CI: 0.21–0.81). Conclusions The iCCM has been found to be an effective and feasible strategy to save infant lives in hard-to-reach communities in Nicaragua. The impact was likely mediated by increased use of curative interventions, made accessible and available at the community level, and delivered through high-quality services, by brigadistas.

RESUMEN Objetivo Describir el programa nicaragüense de atención integrada en la comunidad destinado a las comunidades rurales de difícil acceso y evaluar sus efectos a partir de los datos de seguimiento, como los datos censales anuales sobre la mortalidad infantil (menores de 1 año). Método Este estudio de observación tuvo como objetivo valorar la ejecución de la atención integrada en la comunidad y medir las tendencias de la mortalidad infantil (menores de 1 año) entre el 2007 y el 2013 en 120 comunidades nicaragüenses remotas donde los brigadistas brindan servicios de atención integrada en la comunidad a niños de 2 a 59 meses. El estudio se valió de datos programáticos de seguimiento obtenidos de los registros y las listas de verificación utilizadas para la supervisión de los brigadistas, así como datos de mortalidad derivados de los censos anuales realizados por el Ministerio de Salud. Se calculó la razón de mortalidad (defunciones de lactantes por cantidad de menores de un año vivos) y se informaron estimaciones puntuales e intervalos de confianza binomiales exactos. Resultados Los datos de seguimiento mostraron una ejecución sólida del programa de atención integrada en la comunidad en el período del estudio, dado que la disponibilidad de medicamentos, los registros completos y la clasificación correcta siempre superaron el 80%. Como parte del tratamiento proporcionado contra la neumonía y la diarrea, los brigadistas llevaron a cabo un seguimiento minucioso de los casos previstos y los cuidadores solicitaron tratamiento de los brigadistas con más frecuencia que de los establecimientos de salud. La razón de mortalidad infantil (menores de 1 año) disminuyó más en las zonas atendidas por el programa que en aquellas no atendidas. Se observó una disminución estadísticamente significativa del 52% en el 2010 (razón de la tasa de mortalidad 0,48; IC del 95%: 8%-75%) al 59% en el 2013 (razón de la tasa de mortalidad 0,41; IC del 95%: 19%-79%). Conclusiones El programa de atención integrada en la comunidad es una estrategia eficaz y factible para salvar la vida de los lactantes en las comunidades de difícil acceso de Nicaragua. Estos efectos probablemente estuvieron mediados por la mayor prestación de intervenciones curativas, que estuvieron accesibles y disponibles en el ámbito de la comunidad, y fueron brindadas por los brigadistas por medio de servicios de buena calidad.

RESUMO Objetivo Descrever o programa de manejo integrado de casos na comunidade (iCCM) para comunidades rurais e de difícil acesso na Nicarágua e avaliar seu impacto usando dados de monitoramento, inclusive dados censitários anuais de mortalidade infantil. Método Este estudo observacional avaliou o nível de implementação da estratégia iCCM e calculou tendências de mortalidade infantil nos anos 2007-2013 em 120 comunidades remotas da Nicarágua onde “brigadistas de saúde” prestam serviços de iCCM para crianças de 2 a 59 meses de idade. Foram utilizados dados de monitoramento obtidos dos cadastros e checklists de supervisão de brigadistas e dados de mortalidade obtidos dos censos anuais realizados pelo Ministério da Saúde. Foi calculado o coeficiente de mortalidade infantil (número de óbitos infantis dividido pelo número de crianças menores de 1 ano vivas), além de estimativas pontuais e intervalos de confiança (IC) binomiais exatos. Resultados Os dados de monitoramento evidenciaram forte implementação da estratégia iCCM durante o período de estudo; a disponibilidade de medicamentos, a integralidade dos registros e a classificação correta sempre excederam 80%. O tratamento da pneumonia e da diarreia por brigadistas acompanhou de perto o número de casos esperado, e os responsáveis pelas crianças sistematicamente buscaram tratamento com maior frequência junto aos brigadistas do que nos serviços de saúde. O coeficiente de mortalidade infantil diminuiu mais nas áreas com iCCM do que nas áreas sem iCCM. A redução foi estatisticamente significante, variando de 52% em 2010 (razão de taxa de mortalidade: 0,48; IC95%: 8%–75%) a 59% em 2013 (razão de taxa de mortalidade: 0,41; IC95%: 19%–79%). Conclusões Constatou-se que a iCCM é uma estratégia eficaz e viável para salvar vidas de crianças em comunidades de difícil acesso na Nicarágua. O impacto provavelmente foi mediado pelo aumento do uso de intervenções resolutivas, disponibilizadas de maneira acessível no âmbito da comunidade, através do serviço qualificado prestado pelos brigadistas.