Malaria in PregnancyPopulation Interventions: Cochrane+ Review Atun R, de Jongh T, Secci F, et al, A systematic review of the evidence on integration of targeted health interventions

© Professor Rifat Atun. Imperial College London 2012

Professor Rifat Atun MBBS MBA FRCGP FFPH FRCP Professor of International Health Management Imperial College Business School and Faculty of Medicine Imperial College London

Malaria in Pregnancy An analysis of achievements and limitations to meeting Women’s comprehensive needs during pregnancy Istanbul Imperial College London 26-28 June 2012

© Professor Rifat Atun. Imperial College London. 2012

Figure 1

Source: The Lancet 2010; 376:1485-1496 (DOI:10.1016/S0140-6736(10)61302-5)

ODA for maternal and newborn health for 68 Countdown priority countries, 2008


Figure 3


ODA for maternal and newborn health per livebirth vs maternal mortality for 68 Countdown priority countries, 2008


Figure 2

Source: Hay, Gething, Atun Snow. The Lancet 2010; 376:1409-1416 (DOI:10.1016/S0140-6736(10)61340-2)

Equity of funding for malaria control


Figure 3

Source: Hay, Gething, Snow, Atun: The Lancet 2010; 376:1409-1416 (DOI:10.1016/S0140-6736(10)61340-2)

Adequacy of malaria funding


Prevention, 42%

Treatment, 31%

Source: Global Fund, unpublished Enhanced Financial Reporting data, 2008

Global Fund Expenditures by Service Delivery Area for Malaria (cumulative, by 2008 reporting cycle)

Diagnosis, 2%

Other preven3ve ac3vi3es, 3%

Vector control (other than ITNs), 4%

Malaria preven3on during pregnancy, 2%

Home-‐based management of malaria, 1%




Health innovations diffuse very slowly

•  1601: James Lancaster demonstrates lemon juice cures scurvy

•  1749: Repeated by Lind –  1753 “A treatise of the scurvy”

•  1795: Royal Navy acts on evidence •  1865: Merchant Navy acts on evidence


Poor diffusion of innovation Use of antimalarial drugs in children <5

Source: DHS, MICS and MIS surveys conducted 2006-2008

0102030405060708090

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Gambia

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Ghana

Liberia

Camero

on

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in

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Guinea

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au

Zambia

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Zanzib

arTog

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e

NigeriaNige

r

Sierr

a Leo

neDRC

Angola

Mala

wi

Kenya

Kenya

Ghana

Moz

ambiq

ue

Mau

ritan

ia

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rial G

uinea

Ethiop

ia

Rwanda%

chil

dre

n <

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reat

ed w

ith a

nti

nal

aria

l .

treated with other anti-malarial

treated with ACT

Slide source: WHO/GMP, WMR 2009


Figure 2



Coverage for interventions across the care continuum: 68 priority countries (2000‐06)


Antenatal coverage and PMTCT uptake

Figure 3.12

Preventing mother-to-child transmissionCoverage of antenatal care services and services for preventing mother-to-child transmission among women living with HIV in high-prevalence countries, 2010

Source: WHO and UN Statistics Division

123456789

10111213141516

AngolaBotswanaBurundiCameroonChadCôte d’IvoireD.R. CongoEthiopiaGhanaKenyaLesothoMozambiqueNigeriaSouth AfricaUgandaZambia

PMTCT coverage, ANC coverage and number of HIV+ pregnant women (bubble size)

Source: WHO and UN Statistics Division in UNAIDS Global Report 2010


Figure 4


Proportion of livebirths attended by skilled personnel in 34 Countdown countries with nationally representative measurements around 2000 and around 2008


Proportion of women attending antenatal care receiving second dose of IPTp (2010)

Source: WHO WMR 2011


Proportion of all pregnant women receiving the second dose of IPTp (2009-11)

Source: WHO WMR 2011

© Professor Rifat Atun. Imperial College London 2012

Is integrated care delivery the solution to address poor uptake of innovations?


Primary Community Secondary

Care domain

Services or programs

a. Unintegrated

Primary Community Secondary Primary Community Secondary

b. Partial integration c. Horizontal or vertical integration

Potential integration strategies within and across care domains

Atun et al.: Integration of priority population, health and nutrition interventions into health systems: systematic review. BMC Public Health 2011 11:780. 18


Integrated delivery models – HNP interventions

Programme Intervention Outcome

IMCI (Adam 2005, Arifeen 2004, Bryce 2005, Armstrong Schellenberg 2004)

Multi-country CBA in 12 countries Integration of IMCI in services in vs. routine care

Improved case management, quality of care and under-5 mortality. Costs lower.

PRISM-E (Bartels 2004, Krahn 2006, Oslin 2006)

Integrated delivery of mental health and/or substance abuse services for elderly in PHC setting

Improved patient engagement

Substance abuse & PHC (Weisner 2001, Willenbring 1999

Substance abuse treatment with integrated medical treatment of substance abuse-related co-morbidities

Improved abstinence. Cost effective

Mental health provision in PHC (Gater 1997, Watts 2007)

Depression and schizophrenia treatment integrated into PHC

Improved access and treatment, resources more effectively used

Atun et al.: Integration of priority population, health and nutrition interventions into health systems: systematic review. BMC Public Health 2011 11:780.


Integration of Targeted Health, Nutrition and Population Interventions: Cochrane+ Review

Atun R, de Jongh T, Secci F, et al, A systematic review of the evidence on integration of targeted health interventions into health systems. Health Policy & Planning 2010; 25 :1-14


Integrated delivery of PMTCT: Cochrane Review

Tudor Car L, van-Velthoven MH, Brusamento S, Elmoniry H, Car J, Majeed A, Atun R, Integrating prevention of mother-to-child HIV transmission (PMTCT) programmes with other health services for preventing HIV infection and improving HIV outcomes in developing countries., Cochrane Database Systematic Review 2011

One study •  Integra3ng HIV tes3ng and NVP

adherence assessment at labour ward resulted in substan3al increase in mother-‐infant NVP coverage.

•  No research assessing the impact on coverage of integra3ng with other perinatal PMTCT interven3ons



Adoption of innovations:

global health systems at crossroads:


Key barrier (1): linear view of innovation adoption


Key barrier (2): limited evidence

Methodological challenges in generating evidence

What works in practice and what has worked less well

Optimal delivery models?

Scale and learning effects?

1

2

3

4

Suboptimal solutions

implemented Sources of resistance to policy translation


Key barrier (3): imbalance in health and financing policies

Industrial policies encourage technology push, but health systems constrain innovation:

– Not enough emphasis on demand side factors –  Inadequate incentives and downstream rewards

for adoption –  Inefficiency/ineffectiveness tolerated – No incentives for innovation

Atun RA, Gurol-Urganci I, Sheridan D. Uptake and diffusion of pharmaceutical innovations in health systems. International Journal of Innovation Management 2007; 11 (2): 299-321


Key barrier (4): institutional logic

•  Resistance to innovation

•  Overdue emphasis on technology innovation


Technology overdrive



Innovative Mechanisms for Financing

Fisk NM, McKee M, Atun R. Relative and absolute addressability of global disease burden in maternal and perinatal health by investment in R&D. Trop Med Int Health 2011. Apr 7. doi: 10.1111/j.1365-3156.2011.02778.x.


Diffusion of innovations in complex systems

Intervention Adoption System

Broad Context

Broad Context

Health System Characteristics

Problem

Atun R, et al. A systematic review of the evidence on integration of targeted health interventions into health systems. Health Policy and Planning 2010; 25: 1-14.


A systems approach to innovation

1.  Problem perception

2.  Innovation

3.  Adoption System

4.  Health System

5.  Context

•  Burden •  Necessity and urgency

•  Complexity •  Scalability

•  Receptivity •  Opportunity •  Feasibility

•  Desirability •  Logic

Atun et al. Health Policy and Planning 2010


Thank you

Documents

Malaria in PregnancyPopulation Interventions: Cochrane+ Review Atun R, de Jongh T, Secci F, et al, A systematic review of the evidence on integration of targeted health interventions