Saving Newborn lives Initiative-aka Hala Project - Nipccd

FORM 1: Background and screening data sheet of each considered "Intervention"
Thematic area: Community-Based Newborn Care
Section A: Background
Sl. Topic Description
1 Intervention name The Hala Project, Pakistan (Pilot phase)
2 Location (urban/rural, block, district, state) & time period 315 villages Hala and Matiari sub districts of Pakistan; 2003-2005
3 Objectives To study effect of a package of community-based interventions to reduce perinatal and neonatal mortality, delivered through
community-based Lady Health Workers (LHWs) and Traditional Birth Attendants (TBAs)
4 Lead agencies Department of Pediatrics & Child Health, Aga Khan University, Karachi, Pakistan
5 Scale/coverage 315 villages in Hala and adjoining Mattiari talukas; 1, 38,000 population
6 Key strategies Training LHWs in basic newborn care, community mobilization and health education
Training of TBAs (dais) on basic newborn care, including basic resuscitation and immediate newborn care
Community education and mobilization-use of community volunteers to establish village-level community health committees
for maternal and newborn care and organize group health education sessions
7 Key contacts/champions Dr Zulfiqar A. Bhutta, Professor of Paediatrics & Child Health, Aga Khan University, Karachi, Pakistan
Information collected from: Report on the pilot study entitled “Implementing Community-Based Perinatal Care: Results from a Pilot Study in Rural Pakistan”; And from Internet search articles; (1) Child and
Adolescent Health and Development. Progress Report 2006, WHO; (2) Research Plans and Progress Journal of Perinatology ( 2002 ) 22, S12 – S19; by: Dr D. S Panwar on: July-August 2007
Section B: Screening information
1 Is evaluation data available, indicating the "intervention" impact, outcomes or
outputs?
2 Are there standardized process? Are the key processes documented (with
agreed upon guidelines and approaches)?
Yes. Decreases in the stillbirth rate (from 66 to 43 per thousand total births) and early Neonatal Mortality Rate [(NMR) from 48
to 31 per thousand live births)has been reported in the intervention villages]
Information not adequate to comment on this aspect
3 Has it been implemented in at least two different setting (districts, states or Yes. The intervention took place in 315 villages across two sub-districts of Pakistan
neighboring countries)?
4 Does the intervention focus on family, HH & community level improvements? Yes. The project uses community volunteers to establish village-level community health committees for maternal and newborn
care and organize group health education sessions.
The LHWs are asked to identify all pregnant women and make home visits during pregnancy and within 24 hours of birth, and
to additional visits on days three, seven, 14 and 28 after delivery
5 Is it implemented at block level or above? Yes. 315 villages across two sub-districts of Pakistan form the study area
6 Are there indications that the intervention could be adapted and implemented in Yes. The study area comprises largely an agrarian population with development indicators typical of rural Sindh in Pakistan
different socio-cultural settings?
7 Are there indications that the intervention is not extremely expensive (in terms of
time, funding, personnel) or is competitive in relation to the cost to the current
dominant approaches and models?
Section C: Included in Evidence Review
(ER) - Yes/No
Comments on the parameters that are not addressed above:
Costing information not available
Yes
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Form 2: Evidence Review for Community-Based Newborn Care
Name of Intervention: Hala Project (Pilot phase), Pakistan
Date of Review: August 2007
1. Location and scale
Number of villages by block, district and
state names
315 villages Hala and Matiari sub districts of
Pakistan
2. Agencies
Lead agency(ies) Other key agencies
(partners)
Department of Pediatrics & London School of Tropical
Child Health Aga Khan Medicine and Hygiene
University, Karachi, Pakistan Govt. of Sindh
2. Intervention Description
Population covered Comments Time period
138,600 2003-2005
Implementing agencies Sponsor/donor Comments
List Type (Govt./NGO/private) 1.World Health Organization
1. Department of Health
1. Government of Sind, Pakistan (WHO
2.Aga Khan University
2. Save the Children (funded
by Bill and Melinda gates
Foundation)
Goal and Objectives Key strategies Key components/activities Primary target
group
Secondary target group
Goal: To study effect of a package of 1.Training LHWs in home-based newborn care, 1. Household visits and health education by LHWs to mothers Pregnant Women of reproductive age,
community-based interventions to community mobilization and health education
during pregnancy and post-delivery (within 24 hours of birth mothers adolescent girls, community
reduce perinatal and neonatal
and days three,seven,14 and 28)
elders and local political leaders
mortality, delivered through
2.Training of TBAs (dais)-on basic newborn care, 2. Delivery care by TBAs
community-based Lady Health including basic resuscitation and immediate newborn 3. The community-based interventions included identification
Workers (LHWs) and Traditional Birth care
of community volunteers, formation of Community Health
Attendants (TBAs)
Committees (CHC), organizing emergency transport fund,
3. Community education and mobilization-use of
group education sessions by LHWs, and advocacy work
community volunteers to establish village-level
with community elders and local political leaders to promote
community health committees for maternal and
maternal and newborn care
newborn care and organize group health education 4. Development of local Behavior Change Communication
Information sources
sessions
(BCC) material including a two part video docudrama in
local language (Sindhi)
5. Training of LHWs and TBAs in intervention area
6. Training in basic and intermediate newborn care to all public
sector Rural Health Centre and hospital-based medical and
nursing staff in intervention and control clusters
Publication names Websites)/on-line Unpublished project documents Comments
1. Child and Adolescent Health and Development; Progress Report 2006, WHO
“Implementing Community-Based Perinatal
Care: Results from a Pilot study in Rural
2. Research Plans and Progress Journal of Perinatology ( 2002 ) 22, S12 – S19 SNL-
Bangladesh Program Evaluation, Jan 2005, Save the Children
Pakistan”
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5. Monitoring and Evaluation
Methodology/design
(adopted for program Monitoring and Evaluation data
collection – summarize it from monitoring, baseline, special
studies, midterm or final evaluation reports that you are
referring)
Eight clusters were randomly selected for the pilot study
(which would guide the final effectiveness trial)
A complete household and facility survey was conducted in
these eight clusters from May - June 2003 to assess
socio-economic characteristics and baseline perinatal and
neonatal mortality rates
All births and deaths in the preceding 12 month period were
identified by recall
Four of the eight clusters were chosen to receive the
intervention. Choice was based on trying to ensure that the
intervention and control clusters had similar distributions with
respect to population size, number of births and neonatal
deaths in the preceding 12 months, but did not use a formal
randomization procedure
In addition to the baseline survey in mid 2003, two
cross-sectional surveys of all households were conducted by a
separate census team at the midpoint (June-July 2004) and at
the end of the pilot phase (August –September 2005) to collect
data on births, deaths and care seeking patterns in the
preceding 12 months
Key measures/indicators Key lessons learnt
1. % mothers who received tetanus toxoid during
pregnancy
2. % mothers who received antenatal check-up during
last pregnancy
3. % mothers who received maternal newborn health
information during pregnancy
4. % mothers who received domiciliary visit by LHW
during the last pregnancy
5. % mothers who procured clean delivery kit before
delivery
6. % mothers who delivered in a government health
facility
7. % deliveries with presence of LHW
8. % of newborns received post-natal visit by LHW after
birth
9. % of newborns examined by LHWs within the first 48
hours after birth
10. % newborns with bathing delayed beyond six hours
11. % mothers who fed colostrums to their babies
12. % mothers who breastfed their infant within an hour
of birth
13. % mothers who breastfed their infant exclusively for
first four months
14. % mothers reported receiving support from the
community health committee during pregnancy
Community health workers can play a major role in delivering effective interventions for
maternal and newborn care, and can do so in collaboration with both TBAs and skilled
care providers
Packages of evidence-based interventions can be delivered through community care and
outreach strategies within the existing health system, and make a difference to newborn
outcomes
Dais and LHWs from the same community collaborated readily and community members
(both males and females) were generally receptive to their messages and group sessions
Community group counseling sessions may be a powerful, low-cost and effective means
of reaching large numbers of women in rural settings and may also influence other
community members
Although the overall number of skilled attendants in the area did not change during the
period 2003-5, the proportion of births attended by skilled attendants within the public
sector facilities increased substantially in the intervention clusters indicating that
community support strategies and demand creation affect care seeking
behaviors and neonatal mortality
The observed increase in skilled attendant utilization in these public health facilities
underscores the importance of health system strengthening as a complement to
community-based approaches
Health staff retention was an issue. For example, of the 28 medical officers in the eight
clusters trained in neonatal care and resuscitation, 19 (68%) were transferred out during
the course of the pilot study, including the pediatrician in the district referral hospital.
There were three different director generals of health in the area during the period
2002-2005, placing a large burden on project staff with respect to communication and
consensus building with health system managers and staff
6. Program cost
Total per year Estimated cost per component Estimated cost per beneficiary/unit Comments
Information on cost not
A full analysis of costs and cost-effectiveness
available
analysis is planned for the main trail currently
being implemented in 16 clusters. Results
should be available in late 2008
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FORM 3 - Data sheet for Effectiveness-Community-Based Newborn Care
Name of Intervention: Hala Project (Pilot phase), Pakistan
List of "impact" indicators with
achievements
Intervention clusters: Stillbirth rate
reduced from 66 per 1000 births at
baseline to 43 at endline (Mantel-
Haenszel risk ratio = 0.66 (95% C.I. 0.53,
0.83; P

Form 5 - Expandability Data
Thematic Area: Community-Based Newborn Care
Name of the Intervention: Hala Project (Pilot phase)
Sl. Broad issues
No
1 Simplicity and clarity (is the
intervention clear and simple, are
the components clear and simple?
could it possibly be simplified and
still have results? does it take long
to get results?)
2 Key processes documented (are the
key processes well documented?)
Available information
a) Project notes
Yes. The intervention is clear focusing on delivery of a package of communitybased
interventions to reduce neonatal mortality through community-based
workers-Lady Health Workers (LHWs) and Traditional Birth Attendants (TBAS).
The components of LHW training, dai training and community mobilization are
clear. The dai training in less intensive than those tried out in other interventions.
Focus is on community behaviors, community support strategies and demand
creation
b) Originator’s comments:
a) Project notes: Available information not adequate to comment
b) Originator’s comments:
“Yes, we have process documentation for all the key processes throughout the life
of the project, in which there are / were some periodic and some of them were
regular.
Training of HCP (HCFS including doctors, paramedics, LHVs, LHWs, TBAs). From
all theses trainings we have the number of person’s trained at each facility, pre
and post test results for all the trainings.
Health system strengthening / information:
New borns assessment by LHWs / CHWs by conducting visit on days 0,3,7,14 &
28th day on monthly basis, Home base delivery, HCFs base delivery, Private
HCFs base delivery, Skilled Birth Attendants ( SBAs) delivery, “NVDs”, sick
newborns seen by LHW, sick newborns referred by LHW, sick newborns seeking
care at HCFS, self referral, referred by LHW.
HCFs MIS: on monthly basis were collected from the respective HCF of both
intervention and control areas.
Pregnant women registered, # of ANC visits, # of deliveries, delivery by SBAs,
# of total births, newborn weighed, Low Birth Weight (LBW), still birth, maternal
deaths, sick < one year.
LHWs HMIS: on monthly basis (monthly LHW reports were also collected from
both sides, pregnant women registered, ANC visits, delivery by SBAs, referred to
HCF, newborn weighed, LBW, women examined within 24 Hrs of delivery,
miscarriages, live births, still births, ENDs, LNDs, maternal deaths, referred

3 Feasibility for Govt. system to
implement
(could the Govt. system assimilate
this intervention relatively easily,
does it match well with current Govt.
systems and capacities, does it
require a minimum of new learning,
new inputs, and change)
4 “Dependencies” (what does the
intervention’s success depend on?
For eg. strong PRI/local self
government institution, strong
supervision system, lots of
dedicated NGOs in the area, a
charismatic leader. Does the
intervention have a minimum and
practical no. of dependencies?)
a) Project notes
The intervention utilizes the existing resources available within the Govt. health
system and in the community. The training of Lady Health Workers (LHWs) was
built –upon the standard training being provided under the LHW program in
Pakistan (the LHW program is one of the flagship programs of the Govt. of
Pakistan). In the intervention clusters, a total of six extra days were added to the
standard curriculum to enhance the basic newborn care and community
mobilization components. This is a feasible approach for scale up under the LHW
program. The intervention shows that LHWs can deliver effective interventions for
maternal and newborn care in collaboration with traditional births attendants,
another resource existent in communities. The community mobilization
components like selection of community volunteers, formation of CHCs, group
education sessions, organization of emergency transport funds are additional
activities for LHWs
b) Originator’s comments:
a) Project notes
The project does not create a parallel infrastructure and attempts to deliver the
interventions within the existing health system. Support of the Govt. is critical for
expandability as it utilizes the LHWs for delivery of interventions. Community
mobilization activities such as selection of community volunteers, formation of
CHCs, group education sessions, organization of emergency transport funds
require support dedicated LHWs willing to take additional workload. Since training
of LHWS and TBAs is an important component, capacity to train staff and
availability of resources for the same is a practical requirement
b) Originator’s comments:
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