Lives Saved Tool (LiST) Analysis of Care Group versus Non-Care Group

Child Survival Projects

Christine Marie George, PhD, International Health, JHSPH

Emilia Vignola, MSPH, International Health, JHSPH

Jim Ricca, MD, MPH, ICF Macro

Jamie Perin, PhD, International Health, JHSPH

Henry Perry, MD, PhD, MPH, International Health, JHSPH

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Study Rationale

• Many evaluations of Care Group projects exist, but no systematic assessment of them

• More evidence of effectiveness of Care Groups is needed

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Research Questions

• Do Care Group CSHGP projects achieve greater improvement in high-impact child survival coverage indicators than non-Care Group projects?

• Do Care Group projects achieve greater reductions in the under-five mortality rate than non-Care Group projects?

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Lives Saved Tool (LiST) version 4.68

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High-impact coverage indicators modelled in LiST

•Coverage of 4 antenatal care visits•Multiple micronutrient consumption during pregnancy•Skilled birth attendance•Postnatal preventive care•Exclusive breastfeeding •Appropriate complementary feeding•Handwashing

•Presence of a latrine•Antibiotic treatment of pneumonia•Oral rehydration therapy for diarrhea•Insecticide-treated bed net coverage; malaria treatment; •IPTp coverage•Measles, tetanus and full • immunization coverage•Vitamin A supplementation

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Validation of LiST

Several reports now have validated LiST as a measurement tool for estimating mortality impact

Ricca et al., BMC Public Health 2011•World Relief’s Vurhonga project in Chokwe District, Gaza Province, Mozambique, 1999 to 2003.•An independent evaluation collecting pregnancy history data estimated an under-five mortality declined of 37%. Using project-collected coverage data, LiST produced a corresponding estimate of 39%.

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Previous Studies using LiST

Ricca et al., Health Policy and Planning 2013

Community-based intervention packages facilitated by NGOs demonstrate plausible•12 child survival programs were evaluated•When population coverage changes were modelled in LiST, they were estimated to give a child mortality improvement in the project area that exceeded concurrent secular trend in the subnational DHS region in 11 of 12 cases.

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Child Survival Project Selection

Selection criteria

Care Group projects found at:

http://www.caregroupinfo.org/blog/implementors• Non-Care Group projects found at the USAID

Evaluations Database

http://www.usaid.gov/results-and-data/progress-data/evaluations

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Care Group Eligibility Criteria

Selection criteria: Care Groups• DHS or MICS available for the country where the

Care Group project was conducted within 3 years of both the project baseline and endline

• A Non-Care Group child survival project conducted in the same country within 3 years of the Care Group project.

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Non Care Group Eligibility Criteria

Selection criteria: Non-Care Group projects• There must be a DHS or MICS survey available

within 3 years of their baseline and endline survey• A Care Group project in the same country meeting

the criteria for inclusion

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Excluded Child Survival Programs

26 Child Survival Projects in 8 Countries were Assessed for Eligibility

Care Group projects in three countries were excluded• Liberia (MTI), no matching non-Care Group project• Guatemala (Curamericas), no recent DHS survey

available• Zambia (SAWSO), no recent DHS survey available

Non-Care Group projects excluded in one country• Malawi (PSI) – only nationally implemented• Malawi (STC) – no true baseline or endline surveys

available

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Eligible Child Survival Programs

• 9 Care Group and 12 Non-Care Group child survival projects met these study eligibility criteria.

Care Group

projectsNon-Care Group

projectsCambodia 3 3

Kenya 1 2Malawi 2 1

Mozambique 3 1Rwanda 1 2

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Projects included in the analysis

Country Region Organization Type Project Period

Target area children 0-59 months

Cambodia Kampong Thum

Adventist Development Relief Agency

Non-Care Group 2001-2006 17,477

Cambodia Battambang Catholic Relief

ServicesNon-Care

Group 2001-2006 24,896

CambodiaKampong Chhnang

International Relief and

DevelopmentNon-Care

Group 2006-2010 6,217

Cambodia Siem Reap Red Cross Care Group 2005-2008 43,610

CambodiaKompong

Cham World Relief Care Group 1998-2002 12,167a

CambodiaKompong

Cham World Relief Care Group 2003-2007 12,875

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Projects included in the analysis

Country Region Organization Type Project Period

Target area children 0-59

months

KenyaWestern Province

African Medical and Research

Foundation Non-Care Group 2005-2010 31,644Kenya Rift Valley HealthRight Non-Care Group 2006-2010 48,844

Kenya Coast Plan Care Group 2004-2009 46,354

MalawiSouthern Region

International Eye Foundation Non-Care Group 2002-2006 42,500

Malawi Northern Region World Relief Care Group 2000-2004 36,732

Malawi Northern Region World Relief Care Group 2005-2009 32,025

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Projects included in the analysis

Country Region Organization Type Project Period

Target area children 0-59

months

Mozambique SofalaFood for the

Hungry Care Group 2006-2010 60,666

Mozambique SofalaFood for the

Hungry Care Group 2009-2010 83,778

Mozambique

Manica and Sofala

ProvincesHealth Alliance

International Non-Care Group 2002-2007 97,200

Mozambique Gaza Province World Relief Care Group 2004-2009 33,451

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Projects included in the analysis

Country Region Organization Type Project Period

Target area children 0-59 months

RwandaButare

Province ConcernNon-Care

Group 2001-2006 24,494

Rwanda Kibungo

International Rescue

CommitteeNon-Care

Group 2001-2005 109,700

Rwanda Cyangugu World Relief Care Group 2001-2006 24,021

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Modelling in LiST

• Assumption: beginning under 5 mortality rate for the project area is assumed to be the same as that for the region of the project (based on DHS data)

• LiST estimates the under-5 mortality rate at the end of the project according to changes in coverage of key child survival indicators

• The average annual change in under-5 mortality rate is calculated taking into account the length of the project

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High Impact Child Survival Indicator Coverage Changes

ANC4: 4 antenatal care visits; TT2: 2 doses of tetanus toxoid; IFA: multiple micronutrient supplementation (iron and folic acid); IPTp: intermittent preventive treatment of malaria in pregnancy; SBA: skilled birth attendance; EBF: exclusive breastfeeding; Comp Feed: complementary feeding; PPV: postnatal preventive visit; Vit A: Vitamin A supplementation; ITN: insecticide-treated net; Meas: measles vaccination; Full Vacc: full vaccination with EPI vaccines; Hand Wash: hand washing with soap; ORT: oral rehydration therapy; Abx Pneum: antibiotics for pneumonia; Mal Treat: effective anti-malarial treatment

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Under Age 5 Mortality Rates (U5MR)

Country

Care Group Projects

(N)

Non-Care Group Projects

(N)

Cambodia -5.52% (3) -4.23% (3)

Kenya -3.78% (1) -3.21% (2)

Malawi -3.23% (2) -3.64% (1)

Mozambique -5.18% (3) -3.66% (1)

Rwanda -5.70% (1) -0.94% (2)

Average  -4.68  -3.14

Estimated mean annual percent change in U5MR

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Summary findings

• Overall increase in coverage was significantly higher for Care Group compared to Non Care Group projects (p=0.0007)

• Care Group projects had an estimated mean annual under-5 mortality rate decline that was 49% greater than the non-Care Group projects (p=0.0796).

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Limitations

• Small number of projects included in the analysis• Lack of direct measures of mortality

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Next steps

• Since there are increasing numbers of Care Group projects with data for baseline and endline coverage, a future similar analysis with larger number of projects would be useful

• The growing evidence that Care Groups are effective suggests that there is now a need for randomized controlled trials involving Care Groups.

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Acknowledgments

We are grateful for the support of the LiST Team•Yvonne Tam, MPH•Neff Walker, PhD•Ingrid Friberg, PhD

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Discussion

Is the effect due to the Care Group methodology?• Not clear what specifically it is about the Care Group

methodology that makes it effective (or is it the net combination of characteristics of the methodology?)

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Alternative explanations

• The organizations that implement Care Groups are more effective than organizations implementing non-Care Group projects

• The contexts in which Care Group projects are implemented are more conducing to achieving higher coverage levels (even after controlling for the country of intervention)

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Mean Annual Percent Reduction in Under Age 5 Mortality (U5MR)