Lessons from Immpact: “Making sense of the

evidence”

Julia Hussein

Professor Wendy J Graham

www.immpact-international.org

Emerging evidence culture for policy decision-making

Evidence Values

Resources

Opinion-based decision making

Evidence-based decision making

Pressure on resources

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Sri Lanka Thailand Malaysia

Honduras Egypt Matlab, Bangladesh

Bangladesh MM Survey 2001 India

“Success stories”

China

Immpact is the international research Initiative for Maternal

Mortality Programme Assessment

Sept 2002- to date

Goal: to improve the evidence-base for decision-makers on strategies to reduce maternal & newborn mortality

III. Communication: multi-faceted. e.g. high-profile networking,

12 policy briefs, >100 journal papers, 3 websites, toolkit, etc.

IV. Facilitating uptake of research outputs

II. Outputs:• New tools;• Evidence from major evaluations in 3 main countries + 5 more;• Strengthened research capacity• Launched technical advisory arm (Ipact)

Project cycle 2002- 2008

I. Aim: strengthen the evidence-base on mortality reduction strategies

Evaluations in three main focus countries at sub-national level

• Ghana: effects of free delivery care policy

• Indonesia: effects of village midwife programme

• Burkina Faso: effectiveness of skilled delivery care initiative

What can we reasonably expect of evidence?

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?Trend from a “magic bullet”

?Secular trend with “development”

?Trend from evidence-informedstrategies

The good news - population coverage of “skilled attendants” increased at sub-national levels where:

• More personnel were provided at health centres: evidence from Burkina Faso

• Financial barriers were reduced: evidence from Ghana

• Midwives practised close to the community: evidence from Indonesia

……….BUT….

Immpact key message

Skilled Care at Delivery: the complete “package”

Skills to promote utilisation of

delivery care and to conduct normal

deliveries

Skills to provide basic emergency

obstetric care

Skills to provide comprehensive

emergency obstetric care

Referral

Skilled attendants

Community

Enabling environment

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Poorest Poor Middle Rich Richest

Before fee exemption

After fee exemption

% of deliveries in health facilities by wealth quintiles

Utilisation of delivery care before & after fee exemption in Ghana

Serang and Pandeglang (2004-2006)

Wealth quartile

Poorest

Low middle

Upper middle

Richest

Source: Immpact data;

Relationship between maternal mortality & delivery with skilled attendants: Indonesia

Proportion attended by skilled

attendant

Maternal deaths per 100,000 live births (95% CI)

Yes 10% 2303 (1487-3292)

No 90% 541 (420-684)

Yes 17% 1218 (773-1830)

No 83% 278 (201-373)

Yes 33% 778 (541-1076)

No 67% 280 (195-388)

Yes 71% 257 (181-351)

No 29% 202 (107-334)

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sMillennium Development Goal 5a* is off-track

MM Target

% deliveries with skilled attendants

100%

50%

0%

* 75% reduction in maternal mortality ratio from 1990-2005

“Quality facility deliveries”

“Ensuring that the care received is good quality will enable substantial additional benefits to be reaped in terms of fewer deaths to mothers& babies.” (p.50)

Importance of financial cover for catastrophic costs for maternal care: Indonesia

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Cases (poorest to richest)

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(Rp

. mill

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)

Household income

Household income after catastrophic payments (without Askeskin)

Poverty level

Poverty level

Higher income

An example of a phased strategy for West JavaD

epth

Breadth

Banten - universalAttended delivery + catastrophic

care for all ($1.22 per capita plus investment)

Banten - possible transitionCatastrophic care + SBA in poorest 40% sub-districts +

small transport/incentive allowance ($0.47 or $0.92 per

capita with EmOC for all)

Public health spending $8 pc (Indonesia)Maternal Health $0.3 pc (Banten)

Potential of skilled birth attendants to reduce maternal and newborn mortality is contingent on effective coverage of a package of quality care at delivery (missed opportunity)

Phased options for overcoming implementation bottlenecks to effective coverage are context-specific (no one size fits all)

Implications

Context,

Context,

Context.

‘Science’ of quality improvement interventions

– adequate resources; – active engagement of health professionals; – sustained managerial focus; – multi-faceted interventions; – coordinated action throughout health system; – major investment in training; – availability of robust & timely monitoring.

Context-specific implementation package

Crucial translation step

Research priority-setting

Knowledge-generation & dissemination

Evidencetranslation

Policy-making processes

Source: Alliance for Health Policy and Systems Research. 2007.

Who should do translation of research evidence?

Knowledge brokers work at the interface between research organizations and their target audiences.

http://www.research-transfer.org

Knowledge brokers aim to provide evidence that is accessible, timely, credible and trusted, and packaged in user-friendly format, relevant to the local context.

Media

Advocates, civil society, NGOs, parliamentarians

Research institutions

Think tanks

Funding bodies

Government bodies

Demand for evidence is now more diverse

Researchers are from Venus.

Policy makers are from Mars.

Different worlds, different “communities”

Way forward for academies?

I. Robust descriptions of context to help share lessons

II. Evidence bases built around context

III. Stronger support for local-level data for local decision-makers

IV. More serious discussion of context-specific, phased & staged strategies

V. Strengthened translational skills to boost evidence uptake

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hsMaternal mortality trends: United Kingdom

“The great blot on public health

administration”Minister of Health, 1935

*