Comparing estimates of child mortality reduction modelled in LiST with pregnancy history survey data for a community-based NGO project in Mozambique.

BACKGROUND: There is a growing body of evidence that integrated packages of community-based interventions, a form of programming often implemented by NGOs, can have substantial child mortality impact. More countries may be able to meet Millennium Development Goal (MDG) 4 targets by leveraging such programming. Analysis of the mortality effect of this type of programming is hampered by the cost and complexity of direct mortality measurement. The Lives Saved Tool (LiST) produces an estimate of mortality reduction by modelling the mortality effect of changes in population coverage of individual child health interventions. However, few studies to date have compared the LiST estimates of mortality reduction with those produced by direct measurement. METHODS: Using results of a recent review of evidence for community-based child health programming, a search was conducted for NGO child health projects implementing community-based interventions that had independently verified child mortality reduction estimates, as well as population coverage data for modelling in LiST. One child survival project fit inclusion criteria. Subsequent searches of the USAID Development Experience Clearinghouse and Child Survival Grants databases and interviews of staff from NGOs identified no additional projects. Eight coverage indicators, covering all the project's technical interventions were modelled in LiST, along with indicator values for most other non-project interventions in LiST, mainly from DHS data from 1997 and 2003. RESULTS: The project studied was implemented by World Relief from 1999 to 2003 in Gaza Province, Mozambique. An independent evaluation collecting pregnancy history data estimated that under-five mortality declined 37% and infant mortality 48%. Using project-collected coverage data, LiST produced estimates of 39% and 34% decline, respectively. CONCLUSIONS: LiST gives reasonably accurate estimates of infant and child mortality decline in an area where a package of community-based interventions was implemented. This and other validation exercises support use of LiST as an aid for program planning to tailor packages of community-based interventions to the epidemiological context and for project evaluation. Such targeted planning and assessments will be useful to accelerate progress in reaching MDG4 targets.

Examining the evidence of under-five mortality reduction in a community-based programme in Gaza, Mozambique.

Effective implementation of programmes with the community Integrated Management of Childhood Illness model has demonstrated improvements in care-seeking behaviours and utilisation of health services. The child survival programme implemented in Chokwe district of Gaza province, Mozambique, achieved high coverage for bed net use (80%), oral rehydration therapy for children with diarrhoea (94%) and prompt care-seeking from trained providers for children with danger signs. The project also instituted a community-based vital registration and health information system for routine surveillance of births, deaths and childhood illnesses using an extensive network of 2300 volunteers. Evidence from this system indicated a 66% reduction in infant mortality and a 62% reduction in under-five mortality. To check the reliability of the findings, an independent mortality assessment was carried out using a pregnancy history questionnaire with a sample population of 998 women using standard methodologies applied in the Demographic and Health Surveys. The mortality survey showed reductions of 49% and 42% in infant and under-five mortality, respectively. The leading causes of death identified by verbal autopsies were malaria (30%), neonatal causes (17%) and pneumonia (21.3%). These findings suggest that effective community-based partnerships that support the delivery of health services can contribute to mortality reductions.

Care Groups I: An Innovative Community-Based Strategy for Improving Maternal, Neonatal, and Child Health in Resource-Constrained Settings.

In view of the slow progress being made in reducing maternal and child mortality in many priority countries, new approaches are urgently needed that can be applied in settings with weak health systems and a scarcity of human resources for health. The Care Group approach uses facilitators, who are a lower-level cadre of paid workers, to work with groups of 12 or so volunteers (the Care Group), and each volunteer is responsible for 10-15 households. The volunteers share messages with the mothers of the households to promote important health behaviors and to use key health services. The Care Groups create a multiplying effect, reaching all households in a community at low cost. This article describes the Care Group approach in more detail, its history, and current NGO experience with implementing the approach across more than 28 countries. A companion article also published in this journal summarizes the evidence on the effectiveness of the Care Group approach. An estimated 1.3 million households­almost entirely in rural areas­have been reached using Care Groups, and at least 106,000 volunteers have been trained. The NGOs with experience implementing Care Groups have achieved high population coverage of key health interventions proven to reduce maternal and child deaths. Some of the essential criteria in applying the Care Group approach include: peer-to-peer health promotion (between mothers), selection of volunteers by mothers, limited workload for the volunteers, limited number of volunteers per Care Group, frequent contact between the volunteers and mothers, use of visual teaching tools and participatory behavior change methods, and regular supervision of volunteers. Incorporating Care Groups into ministries of health would help sustain the approach, which would require creating posts for facilitators as well as supervisors. Although not widely known about outside the NGO child survival and food security networks, the Care Group approach deserves broader recognition as a promising alternative to current strategies for delivering key health interventions to remote and underserved communities.

Care Groups II: A Summary of the Child Survival Outcomes Achieved Using Volunteer Community Health Workers in Resource-Constrained Settings.

The Care Group approach, described in detail in a companion paper in this journal, uses volunteers to convey health promotion messages to their neighbors. This article summarizes the available evidence on the effectiveness of the Care Group approach, drawing on articles published in the peer-reviewed literature as well as data from unpublished but publicly available project evaluations and summary analyses of these evaluations. When implemented by strong international NGOs with adequate funding, Care Groups have been remarkably effective in increasing population coverage of key child survival interventions. There is strong evidence that Care Groups can reduce childhood undernutrition and reduce the prevalence of diarrhea. Finally, evidence from multiple sources, comprising independent assessments of mortality impact, vital events collected by Care Group Volunteers themselves, and analyses using the Lives Saved Tool (LiST), that Care Groups are effective in reducing under-5 mortality. For example, the average decline in under-5 mortality, estimated using LiST, among 8 Care Group projects was 32%. In comparison, among 12 non-Care Group child survival projects, the under-5 mortality declined, on average, by an estimated 11%. Care Group projects cost in the range of US$3-$8 per beneficiary per year. The cost per life saved is in the range of $441-$3,773, and the cost per disability-adjusted life year (DALY) averted is in the range of $15-$126. The Care Group approach, when implemented as described, appears to be highly cost-effective based on internationally accepted criteria. Care Groups represent an important and promising innovative, low-cost approach to increasing the coverage of key child survival interventions in high-mortality, resource-constrained settings. Next steps include further specifying the adjustments needed in government health systems to successfully incorporate the Care Group approach, testing the feasibility of these adjustments and of the effectiveness of Care Groups in pilot programs in government health systems, and finally assessing effectiveness at scale under routine field conditions in government health programs.