The Accelerated Child Survival and Development Programme, implemented by UNICEF in 11 west African countries* between 2001 and 2005, aimed to reduce child mortality by at least 25% by the end of 2006. However, a retrospective evaluation of the programme in three of these countries—Benin, Ghana, and Mali—did not show an acceleration in child survival. The programme is analysed in an Article published Online First (www.thelancet.com) and in an upcoming edition of The Lancet, written by Dr Jennifer Bryce, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA, and colleagues.
The authors used data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys to compare changes in coverage for 14 ACSD interventions**, nutritional status (stunting and wasting), and mortality in children younger than 5 years in the ACSD focus districts with those in the remainder of every country (comparison areas), after excluding major metropolitan areas.
The authors found that mortality in children younger than 5 years decreased in ACSD areas by 13% in Benin and 20% in Ghana, but neither result was statistically significant. The 24% reduction in Mali was statistically significant. However, these decreases were not greater than those in comparison areas in Benin 25%; Mali 31%; comparison data was not available for Ghana. ACSD districts showed significantly greater increases than did comparison areas in coverage for preventive interventions delivered through outreach and campaign strategies in Ghana and Mali, but not Benin. Coverage in ACSD areas for correct treatment of childhood pneumonia, diarrhoea, and malaria did not differ significantly from before to after programme implementation in Benin and Mali, but decreased significantly in Ghana for malaria (from 78% to 53%) and diarrhoea (from 39% to 28%). The researchers recorded no significant improvements in nutritional status attributable to ACSD in the three countries.
The authors discuss a number of reasons why ACSD did not achieve its aims. Firstly, the importance of directing resources to interventions that prevent the most deaths. Secondly, the need for supportive policies—in the case of pneumonia and diarrhoea, such policies were not widely in force when ACSD was designed (eg, zinc supplementation for diarrhoea prevention). Thirdly, the most well-designed programmes will always falter if drugs are not available or the drug supply is interrupted—for example, artemisinin-based combination therapies for malaria were not available in Benin or Mali until 2007. Fourth, the community component of the ACSD programme was weak. Community-based workers received no remuneration for their work, few nonfinancial incentives, and little supervision.
The research team says that future programmes should learn from these results, and provides examples of steps to be taken: (1) active promotion of country policies supporting community case management for pneumonia and malaria and the incorporation of zinc into the management of diarrhoea; (2) incorporation of simulation models to estimate potential lives saved into programme planning exercises nationally to ensure that decision makers have access to up-to-date information about local causes of child deaths and reliable evidence for intervention effectiveness; (3) definition and implementation of stronger compensation, motivation, and supervision approaches for community-based workers; and (4) strengthening the nutrition component of country programmes. The authors say: "A prospective evaluation is in progress that will provide important intermediate results about efforts to implement these recommendations within the next few years."
They conclude: "The ACSD project did not accelerate child survival in Benin and Mali focus districts relative to comparison areas, probably because coverage for effective treatment interventions for malaria and pneumonia were not accelerated, causes of neonatal deaths and undernutrition were not addressed, and stock shortages of insecticide-treated nets restricted the potential effect of this intervention. Changes in policy and nationwide programme strengthening may have benefited from inputs by UNICEF and other partners, making an acceleration effect in the ACSD focus districts difficult to capture."
In an accompanying Comment, Dr Stefan Peterson, Karolinska Institutet, Global Health (IHCAR), Stockholm, Sweden; and Makerere University, Kampala, Uganda says: "Current research funding overwhelmingly favours development of new technologies over implementation research—eg, the US National Institutes of Health spends 97% of funds on the former and 3% on the latter. Yet the priority for child survival is implementation research on scale-up issues in complex health systems. Increased funding, research and evaluation methods development, and new partnerships between academics and implementers are required to create generalisable knowledge that can accelerate child survival by bridging the know-do gap."
Dr Jennifer Bryce, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. (currently in Geneva) T) +1 607 280 4800 E) jbrycedanby@aol.com / Jbryce@jhsph.edu
Dr Stefan Peterson, Karolinska Institutet, Global Health (IHCAR), Stockholm, Sweden; and Makerere University, Kampala, Uganda. T) +46 70 446 0787 E) Stefan.Peterson@ki.se
For full Article and Comment, see: http://press.thelancet.com/unicefacsd.pdf
Notes to editors:
An Editorial linked to this study will be issued by The Lancet Press Office on Monday 11 Jan, which will have the same embargo of 0001H UK time Tues 12 Jan.
*11 countries: (four high impact) Benin, Ghana, Mali, Senegal (seven 'expansion') Burkina Faso, Chad, Cameroon, Gambia, Guinea Bissau, Guinea Conakry, and Niger
**see panel, p2 full Article
Journal
The Lancet