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Inspiration, Integration and Impact Empowering people for Saving Newborns and Children. - Abhay Bang, SEARCH, GadchiroliTRANSCRIPT
Abhay Bang
SEARCH, Gadchiroli
Empowering people for
Saving Newborns and Children
SEARCH, Gadchiroli
Inspiration, Integration and Impact
Bombay
New Delhi
Maharashtra
Gadchiroli
SEARCH, Gadchiroli
S E A R C H(Society for Education, Action and
Research in Community Health)
SEARCH, Gadchiroli
SEARCH, Gadchiroli
Laboratory of 86 villages
IMR (1988) : 121 /1000 LB
Neonatal 39%
Pneumonia 20%
Diarrhoea 19%
Immunisable Diseases
15%
Malaria 7%
Why do children die ? Main causes
Malnutrition
SEARCH, Gadchiroli
Before Treatment After Treatment
(1988-2003)
Percent Deaths due to Pneumonia
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0
10
20
30
40
50
60
70
80
90
NMR62
IMR : 80
The IMR in Gadchiroli ( 39 villages ) 1990
Newborns in India
27 million newborns are born each year
51 % born at home
Even the hospital delivered mother and newborns are sent home < 24 hr.
Newborn health care must visit where the neonates are.
*
SEARCH, Gadchiroli
SEARCH, Gadchiroli
SEARCH, Gadchiroli
Limitations of hospital care
• Inaccessible
• Costly
• Parents unwilling
• Not enough beds and neonatologists
SEARCH, Gadchiroli
Home-Based Newborn Care
Goal : To reduce neonatal mortality by
developing a low-cost, home-based model
of primary newborn care by using the
human potential in villages.
SEARCH, Gadchiroli
Baseline IMR 76 and NMR 60*
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How to provide HBNC
Mother
TBA
CHW
Supervisor
Training + Supervision + supplies + incentivesSEARCH, Gadchiroli
SEARCH, Gadchiroli
SEARCH, Gadchiroli
•Health education for behavior change & care seeking
•Attending home delivery : with TBA
•Care of baby at birth
•Home visits and support in newborn care
•Monitor the newborns
•Management of NB sicknesses- Birth asphyxia- LBW / Preterm - Sepsis / Pneumonia
Interventions
SEARCH, Gadchiroli
SEARCH, Gadchiroli
SEARCH, Gadchiroli
SEARCH, Gadchiroli
SEARCH, Gadchiroli
SEARCH, Gadchiroli
Supervision: Every 15 days1. Is the work of CHW complete ?
2. Is the quality of work good ?
3. Are her skills up to the mark ?
4. Does she have the supplies ?
5. Are there any complications ?
6. Is the community satisfied & supportive ?
7. How much should she be paid ? SEARCH, Gadchiroli
SEARCH, Gadchiroli
Neonatal mortality rate (1993 to 2003)(intervention and control area)
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
1993-95 1995-96 1996-97 1997-98 1998-01 2001-03Baseline Training
& visiting Interventions Full
InterventionsContinuation of care
Neonatal mortality rate
70 % reeducation in the NMR SEARCH, Gadchiroli
Effect of home-based newborn care on case fatality
(1995-96 Vs 1996-03)
11.3
4.9**
33.3
10.1**
18.5
6.9**
38.5
20.2*
0
5
10
15
20
25
30
35
40
45
Low birth weight Preterm Sepsis Asphyxia
1995-96, Before interventions 1996-03, With interventions
% case fatality
** p < 0.005, * p < 0.07SEARCH, Gadchiroli
The Infant Mortality Rate in Gadchiroli (1988 – 2007)
39 intervention villages
0
20
40
60
80
100
120
140
19881989
19901991
19921993
19941995
19961997
19981999
20002001
20022003-2007
Infant Mortality Rate
Pneumonia case management
Home-based newborn care
Year
Linear regression trend in IMR
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SEARCH, Gadchiroli
*
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SEARCH, Gadchiroli
How to transfer HBNCC from Gadchiroli to India ?
SEARCH, Gadchiroli
ANKUR Project (2001-05)
SEARCH, Gadchiroli
Supported by Save the Children, US
Selected study sites
SEARCH HQ
ANKUR Project
Villages : 91
Slums : 6
Total Population : 88, 311
Tribal
TribalRural
Rural
Rural
U.Slum
Rural
Nashik
Osmanabad
Sangli
Yawatmal
Nagpur
Gadchiroli
SEARCH, Gadchiroli
(2001-05)
46
23
05
101520253035404550
Baseline Intervention 3rd Year
ANKUR : NMR
51 % reduction
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Neonatal 39%
Penumonia 20%
Diarrhoea 19%
Immunisable Diseases
15%
Malaria 7%
A combined package for children 0-5 years age : Home-Based Newborn and Child Care (HBNCC)
1 month – 5 yearCauses of death
IMCI + HBNC = HBNCCSEARCH, Gadchiroli
SEARCH, Gadchiroli
ANKUR Project in Mahatashtra
HBNCC Replication sites
ICMR Study: Government of India, five states.
Other NGOs
Africa
Other Countries
Total 49 Sites
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Other States
4 countries
11th Five Year Plan
• HBNCC Gadchiroli model to be the main strategy to reduce IMR in India.
• Introduce HBNCC in all districts with IMR > 45
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Guidelines of Ministry of Health
Govt. of India (2010)
ASHAs to provide HBNC
Educational Aids from SEARCH
Dialogue with Mother
Home Based Newborn Care
CHW Training Manual
Flip-Chart for Health Education of Mothers
A Film for Health Education of Mothers
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Policy change in Ethiopia
• Management of Pneumonia in children
• Home-Based Newborn Care
Global Policy Acceptance
Joint statement by WHO, UNICEF, US-AID and Save the Children ( 2009).
Endorsement of home visiting the neonates and management of sick neonates at home by trained worker if the referral is not possible.
“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has.”
Margaret Mead
EVERY ONE OF US HAS POTENTIAL TO CHANGE
What can we do?
1. Make the Newborn Your Talisman
2. Don’t provide only health care
But, provide capacity to care for health
3. Empowerment of women is the most sustainable and best strategy
4. Don’t withhold distribution of medical knowledge and skills.
5. Introduce Home-Based Newborn and Child Care wherever you work.
SEARCH, Gadchiroli
Question : Does HBNC conflict
Majority home deliveries is a fact.
After hospital delivery most mothers
discharged on the 2nd day.
Near complete absence of post-partum
care.
60 % maternal deaths occur in the PP period
with Safe Motherhood?
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How does HBNC fit with JSY ?
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Antenatal Delivery
Facility
Home
Post-natal
JSY HBNC
JSY & HBNC are complementary
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HBNC is necessary to all neonates whether born in
institution or at home.
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Does HBNC Affect Maternal Health?
Mortality ?
Morbidity ?
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Home-based
Post partum + Neonatal
care
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IMNCI
Welcome addition of the ‘N’ to IMCI
Training 8 days
NN care 4 days
Does not include
- Asphyxia mgt at birth
- Sepsis mgt with 2 antibiotics
i.e. nearly 60 % deaths
- Expected effect small. SEARCH, Gadchiroli
Integrated HBMNCC
HBNC
+
Maternal Care
+
IMCI
Home-based Mother-Newborn- Child care+ Referral of complicated cases.*
SEARCH, Gadchiroli
Antenatal Delivery
Facility
Home
Post-natal
JSY HBNC
Mother-Newborn and Child Care
SEARCH, Gadchiroli
Facility Based
Newborn care
Child Health
(IMCI)
ASHA + Training and supervision + Health System
Is it ethical ?
• First, advise referral
• Does the ethical responsibility stop with advice?
• What % actually go to hospital?
• What happens if not treated ?
• Case fatality 26 %
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Is it ethical ?
• Is it ethical to let the newborn die?
• Is it ethical to give antibiotic as a life saving emergency measure?
• Other situations
- Insulin for juvenile diabetic child
- Needles for drug addicts
- Cholera vaccineSEARCH, Gadchiroli
ASHA workbook ASHA progress book Story book on ASHAs
Feasibility of Home-based Sepsis Management
(1996-2003)
Parental acceptance
Agreed to hospitalise 2.6 %
Agreed to home-based treatment 91.1 %
Refused both 6.3 %
Proportion of total neonates in community treated by VHWs for sepsis 8.9 %
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We, the adults,
but are best protected by health care.
are at the lowest risk of death,*
*
We reproduce, giving birth to the most vulnerable human beings – the neonates,
*
In a just society, *we should all be hanged !*
and then let them die – 1 million in India, 3.6 million globally, every year
**
Neonatal Sepsis = Pneumonia (52% Deaths) Meningitis Septicemia
6 % to 10 % Neonates need treatment
2 Antibiotics : Oral + Injectable
SEARCH, Gadchiroli, India
Payment to CHW
• Time spent : 1 hr 23 min. / day
per 1000 popl.
• Performance linked payment
• $ 4 Per mother-newborn
• Average $ 10 month
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Cost and cost-effectiveness of home-based neonatal care in Gadchiroli (2001-2003)
(1 US $=45 Indian Rs.)
Non-recurring costs (2002-03 prices ) US $
Annual recurring costs US $
Cost per village Training : 89
Equipments : 66
Total : 155 118
Cost per mother–newborn served
7
Cost per death averted
151
Cost per DALY saved
7
The preceding slides were presented at theCORE Group 2010 Fall Meeting
Washington, DC
To see similar presentations, please visit:www.coregroup.org/resources/meetingreports