‘Scaling-up is a craft not a science’: catalysing scale-up of maternal and newborn health innovations in Ethiopia, India and Nigeria

N Spicer, D Bhattacharya, R Dimka, F Fanta, enter site L Mangham-Jefferies, J Schellenberg, A Tamire Wildemaniam, G Walt, D Wickremansinghe

Social Science & Medicine 2014, 121: 30-38 | DOI: 10.1016/j.socscimed.2014.09.046


Donors and other development partners commonly introduce innovative practices and technologies to improve health in low and middle income countries. Yet many innovations that are effective in improving health and survival are slow to be translated into policy and implemented at scale. Understanding the factors influencing scale-up is important. We conducted a qualitative study involving 150 semi-structured interviews with government, development partners, civil society organisations and externally funded implementers, professional associations and academic institutions in 2012/13 to explore scale-up of innovative interventions targeting mothers and newborns in Ethiopia, the Indian state of Uttar Pradesh and the six states of northeast Nigeria, which are settings with high burdens of maternal and neonatal mortality. Interviews were analysed using a common analytic framework developed for cross-country comparison and themes were coded using Nvivo. We found that programme implementers across the three settings require multiple steps to catalyse scale-up. Advocating for government to adopt and finance health innovations requires: designing scalable innovations; embedding scale-up in programme design and allocating time and resources; building implementer capacity to catalyse scale-up; adopting effective approaches to advocacy; presenting strong evidence to support government decision making; involving government in programme design; invoking policy champions and networks; strengthening harmonisation among external programmes; aligning innovations with health systems and priorities. Other steps include: supporting government to develop policies and programmes and strengthening health systems and staff; promoting community uptake by involving media, community leaders, mobilisation teams and role models. We conclude that scale-up has no magic bullet solution – implementers must embrace multiple activities, and require substantial support from donors and governments in doing so.

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Providers’ knowledge, preference and practice in treating patients with suspected malaria in Cameroon and Nigeria

Quetiapine ohne rezept Lindsay Jean Mangham Jefferies

PhD thesis, London School of Hygiene & Tropical Medicine, 2014.

Awarded 19 August 2014


Working as agents for their patients, health care providers often make treatment decisions on the patient’s behalf. By establishing common standards, clinical guidelines are central to efforts to improve patient care and can expedite the introduction of new technologies. Each year considerable resources are used to disseminate clinical guidelines, though conventional public health interventions often have a limited effect in changing providers’ practice.

Using economic theory and methods, research was undertaken to design and evaluate interventions to support the roll-out of malaria rapid diagnostic testing. This thesis contains five research papers on providers’ knowledge, preference and practice in treating patients with malaria symptoms in Cameroon and Nigeria. In this setting, uncomplicated malaria is routinely diagnosed and treated by health workers in outpatient departments and primary health centres, or self-treated using antimalarials purchased at pharmacies and drug stores.

Major problems with malaria diagnosis and treatment were identified. Relatively few febrile patients were tested for malaria, many did not receive the recommended antimalarial, and when patients were tested for malaria the test result was often ignored when treatment was prescribed. Moreover, there was no significant relationship between providers’ knowledge and their practice, and preferences over alternative antimalarials were similar among providers working in the same facility or locality.

The results of a cluster randomized trial in Cameroon demonstrated that introducing rapid diagnostic tests with enhanced training, which targeted providers’ practice, was more cost-effective than introducing rapid diagnostic tests with basic training, when each was compared to current practice. Since the trial concluded, the Ministry of Health has incorporated the enhanced training in the nationwide roll-out of rapid diagnostic testing.

The findings are also relevant for policy makers elsewhere, and highlight the value in developing strategies to improve providers’ adherence to malaria treatment guidelines when expanding access to malaria testing.

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Cost-effectiveness of strategies to improve the utilization and provision of maternal and newborn health care in low-income and lower-middle-income countries: a systematic review

buy Tastylia Oral Strip online without prescription L Mangham-Jefferies, C Pitt, S Cousens, A Mills, J Schellenberg

BMC Pregnancy and Childbirth 2014, 14:243 | DOI: 10.1186/1471-2393-14-243


Background: Each year almost 3 million newborns die within the first 28 days of life, 2.6 million babies are stillborn, and 287,000 women die from complications of pregnancy and childbirth worldwide. Effective and cost-effective interventions and behaviours for mothers and newborns exist, but their coverage remains inadequate in low- and middle-income countries, where the vast majority of deaths occur. Cost-effective strategies are needed to increase the coverage of life-saving maternal and newborn interventions and behaviours in resource-constrained settings.

Methods: A systematic review was undertaken on the cost-effectiveness of strategies to improve the demand and supply of maternal and newborn health care in low-income and lower-middle-income countries. Peer-reviewed and grey literature published since 1990 was searched using bibliographic databases, websites of selected organizations, and reference lists of relevant studies and reviews. Publications were eligible for inclusion if they report on a behavioural or health systems strategy that sought to improve the utilization or provision of care during pregnancy, childbirth or the neonatal period; report on its cost-effectiveness; and were set in one or more low-income or lower-middle-income countries. The quality of the publications was assessed using the Consolidated Health Economic Evaluation Reporting Standards statement. Incremental cost per life-year saved and per disability-adjusted life-year averted were compared to gross domestic product per capita.

Results: Forty-eight publications were identified, which reported on 43 separate studies. Sixteen were judged to be of high quality. Common themes were identified and the strategies were presented in relation to the continuum of care and the level of the health system. There was reasonably strong evidence for the cost-effectiveness of the use of women’s groups, home-based newborn care using community health workers and traditional birth attendants, adding services to routine antenatal care, a facility-based quality improvement initiative to enhance compliance with care standards, and the promotion of breastfeeding in maternity hospitals. Other strategies reported cost-effectiveness measures that had limited comparability.

Conclusion: Demand and supply-side strategies to improve maternal and newborn health care can be cost-effective, though the evidence is limited by the paucity of high quality studies and the use of disparate cost-effectiveness measures.

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The practice of ‘doing’ evaluation: lessons learned from nine complex intervention trials in action

J Reynolds, D DiLiberto, L Mangham-Jefferies, EK Ansah, S Lal, H Mbakilwa, K Bruxvoort, J Webster, LS Vestergaard, S Yeung, T Leslie, E Hutchinson, H Reyburn, D Lalloo, D Schellenberg, B Cundill, SG Staedke, V Wiseman, C Goodman, CIR Chandler.

Implementation Science 2014, 9:75 | DOI: 10.1186/1748-5908-9-75


Background: There is increasing recognition among trialists of the challenges in understanding how particular ‘real-life’ contexts influence the delivery and receipt of complex health interventions. Evaluations of interventions to change health worker and/or patient behaviours in health service settings exemplify these challenges. When interpreting evaluation data, deviation from intended intervention implementation is accounted for through process evaluations of fidelity, reach, and intensity. However, no such systematic approach has been proposed to account for the way evaluation activities may deviate in practice from assumptions made when data are interpreted.

Methods: A collective case study was conducted to explore experiences of undertaking evaluation activities in the real-life contexts of nine complex intervention trials seeking to improve appropriate diagnosis and treatment of malaria in varied health service settings. Multiple sources of data were used, including in-depth interviews with investigators, participant-observation of studies, and rounds of discussion and reflection.

Results and discussion: From our experiences of the realities of conducting these evaluations, we identified six key ‘lessons learned’ about ways to become aware of and manage aspects of the fabric of trials involving the interface of researchers, fieldworkers, participants and data collection tools that may affect the intended production of data and interpretation of findings. These lessons included: foster a shared understanding across the study team of how individual practices contribute to the study goals; promote and facilitate within-team communications for ongoing reflection on the progress of the evaluation; establish processes for ongoing collaboration and dialogue between sub-study teams; the importance of a field research coordinator bridging everyday project management with scientific oversight; collect and review reflective field notes on the progress of the evaluation to aid interpretation of outcomes; and these approaches should help the identification of and reflection on possible overlaps between the evaluation and intervention.

Conclusion: The lessons we have drawn point to the principle of reflexivity that, we argue, needs to become part of standard practice in the conduct of evaluations of complex interventions to promote more meaningful interpretations of the effects of an intervention and to better inform future implementation and decision-making.

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Designing and implementing interventions to change clinician’s practice in the management of uncomplicated malaria: Lessons from Cameroon

OA Achonduh, WF Mbacham, L Mangham-Jefferies, B Cundill, C Chandler, J Pamen-Ngako, AK Lele, IC Ndong, SN Ndive, JN Ambebila, BB Orang-Ojong, TM Njuabe, M Akindeh-Nji, V Wiseman

Malaria Journal 2014, 13:204 | DOI: 10.1186/1475-2875-13-204


Background: Effective case management of uncomplicated malaria is a fundamental pillar of malaria control. Little is known about the various steps in designing interventions to accompany the roll out of rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT). This study documents the process of designing and implementing interventions to change clinicians’ practice in the management of uncomplicated malaria.

Methods: A literature review combined with formative quantitative and qualitative research were carried out to determine patterns of malaria diagnosis and treatment and to understand how malaria and its treatment are enacted by clinicians. These findings were used, alongside a comprehensive review of previous interventions, to identify possible strategies for changing the behaviour of clinicians when diagnosing and treating uncomplicated malaria. These strategies were discussed with ministry of health representatives and other stakeholders. Two intervention packages – a basic and an enhanced training were outlined, together with logic model to show how each was hypothesized to increase testing for malaria, improve adherence to test results and increase appropriate use of ACT. The basic training targeted clinicians’ knowledge of malaria diagnosis, rapid diagnostic testing and malaria treatment. The enhanced training included additional modules on adapting to change, professionalism and communicating effectively. Modules were delivered using small-group work, card games, drama and role play. Interventions were piloted, adapted and trainers were trained before final implementation.

Results: Ninety-six clinicians from 37 health facilities in Bamenda and Yaounde sites attended either 1-day basic or 3-day enhanced training. The trained clinicians then trained 632 of their peers at their health facilities. Evaluation of the training revealed that 68% of participants receiving the basic and 92% of those receiving the enhanced training strongly agreed that it is not appropriate to prescribe anti-malarials to a patient if they have a negative RDT result.

Conclusion: Formative research was an important first step, and it was valuable to engage stakeholders early in the process. A logic model and literature reviews were useful to identify key elements and mechanisms for behaviour change intervention. An iterative process with feedback loops allowed appropriate development and implementation of the intervention.

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Basic or enhanced clinician training to improve adherence to malaria treatment guidelines: a cluster-randomised trial in two areas of Cameroon

WF Mbacham, L Mangham-Jefferies, B Cundill, OA Achonduh, CIR Chandler, JN Ambebila,  A Nkwescheu, D Forsah-Achu, V Ndiforchu, O Tchekountouo, M Akindeh-Nji, P Ongolo-Zogo, V Wiseman

Lancet Global Health 2014, 2(6):e346-e358 | DOI: 10.1016/S2214-109X(14)70201-3


Background: The scale-up of malaria rapid diagnostic tests (RDTs) is intended to improve case management of fever and targeting of artemisinin-based combination therapy. Habitual presumptive treatment has hampered these intentions, suggesting a need for strategies to support behaviour change. We aimed to assess the introduction of RDTs when packaged with basic or enhanced clinician training interventions in Cameroon.

Methods: We did a three-arm, stratified, cluster-randomised trial at 46 public and mission health facilities at two study sites in Cameroon to compare three approaches to malaria diagnosis. Facilities were randomly assigned by a computer program in a 9:19:19 ratio to current practice with microscopy (widely available, used as a control group); RDTs with a basic (1 day) clinician training intervention; or RDTs with an enhanced (3 days) clinician training intervention. Patients (or their carers) and fieldworkers who administered surveys to obtain outcome data were masked to study group assignment. The primary outcome was the proportion of patients treated in accordance with WHO malaria treatment guidelines, which is a composite indicator of whether patients were tested for malaria and given appropriate treatment consistent with the test result. All analyses were by intention to treat. This study is registered at ClinicalTrials.gov, number NCT01350752.

Findings: The study took place between June 7 and Dec 14, 2011. The analysis included 681 patients from nine facilities in the control group, 1632 patients from 18 facilities in the basic-training group, and 1669 from 19 facilities in the enhanced-training group. The proportion of patients treated in accordance with malaria guidelines did not improve with either intervention; the adjusted risk ratio (RR) for basic training compared with control was 1·04 (95% CI 0·53–2·07; p=0·90), and for enhanced training compared with control was 1·17 (0·61–2·25; p=0·62). Inappropriate use of antimalarial drugs after a negative test was reduced from 84% (201/239) in the control group to 52% (413/796) in the basic-training group (unadjusted RR 0·63, 0·28–1·43; p=0·25) and to 31% (232/759) in the enhanced-training group (0·29, 0·11–0·77; p=0·02).

Interpretation: Enhanced clinician training, designed to translate knowledge into prescribing practice and improve quality of care, has the potential to halve overtreatment in public and mission health facilities in Cameroon. Basic training is unlikely to be sufficient to support the behaviour change required for the introduction of RDTs.

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Evaluation of a universal long-lasting insecticidal net distribution campaign in Ghana: Is it cost-effective to distribute and hang-up malaria bednets?

L Smith Paintain, D Yayemain, S Addei, V Kukula, E Awini, M Gyapong, E Rusamira, J Ageborson, A Chatterjee, L Mangham-Jefferies

Malaria Journal 13:71 | DOI: 10.1186/1475-2875-13-71


Background: Between May 2010 and October 2012, approximately 12.5 million long-lasting insecticidal nets (LLINs) were distributed through a national universal mass distribution campaign in Ghana. The campaign included pre-registration of persons and sleeping places, door-to-door distribution of LLINs with ‘hang-up’ activities by volunteers and post-distribution ‘keep-up’ behaviour change communication activities. Hang-up activities were included to encourage high and sustained use.

Methods: The cost and cost-effectiveness of the LLIN Campaign were evaluated using a before-after design in three regions: Brong Ahafo, Central and Western. The incremental cost effectiveness of the ‘hang-up’ component was estimated using reported variation in the implementation of hang-up activities and LLIN use. Economic costs were estimated from a societal perspective assuming LLINs would be replaced after three years, and included the time of unpaid volunteers and household contributions given to volunteers.

Results: Across the three regions, 3.6 million campaign LLINs were distributed, and 45.5% of households reported the LLINs received were hung-up by a volunteer. The financial cost of the campaign was USD 6.51 per LLIN delivered. The average annual economic cost was USD 2.90 per LLIN delivered and USD 6,619 per additional child death averted by the campaign. The cost-effectiveness of the campaign was sensitive to the price, lifespan and protective efficacy of LLINs.

Hang-up activities constituted 7% of the annual economic cost, though the additional financial cost was modest given the use of volunteers. LLIN use was greater in households in which one or more campaign LLINs were hung by a volunteer (OR = 1.57; 95% CI = 1.09, 2.27; p = 0.02). The additional economic cost of the hang-up activities was USD 0.23 per LLIN delivered, and achieved a net saving per LLIN used and per death averted.

Conclusion: In this campaign, hang-up activities were estimated to be net saving if hang-up increased LLIN use by 10% or more. This suggests hang-up activities can make a LLIN campaign more cost-effective.

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What determines providers’ stated preference for the treatment of uncomplicated malaria?

L Mangham-Jefferies, K Hanson, W Mbacham, O Onwujekwe, V Wiseman

Social Science & Medicine 2014, 104:98-106 | DOI: 10.1016/j.socscimed.2013.12.024


As agents for their patients, providers often make treatment decisions on behalf of patients, and their choices can affect health outcomes. However, providers operate within a network of relationships and are agents not only for their patients, but also other health sector actors, such as their employer, the Ministry of Health, and pharmaceutical suppliers. Providers’ stated preferences for the treatment of uncomplicated malaria were examined to determine what factors predict their choice of treatment in the absence of information and institutional constraints, such as the stock of medicines or the patient’s ability to pay.

518 providers working at non-profit health facilities and for-profit pharmacies and drug stores in Yaoundé and Bamenda in Cameroon and in Enugu State in Nigeria were surveyed between July and December 2009 to elicit the antimalarial they prefer to supply for uncomplicated malaria. Multilevel modelling was used to determine the effect of financial and non-financial incentives on their preference, while controlling for information and institutional constraints, and accounting for the clustering of providers within facilities and geographic areas.

69% of providers stated a preference for artemisinin-combination therapy (ACT), which is the recommended treatment for uncomplicated malaria in Cameroon and Nigeria. A preference for ACT was significantly associated with working at a for-profit facility, reporting that patients prefer ACT, and working at facilities that obtain antimalarials from drug company representatives. Preferences were similar among colleagues within a facility, and among providers working in the same locality. Knowing the government recommends ACT was a significant predictor, though having access to clinical guidelines was not sufficient.

Providers are agents serving multiple principals and their preferences over alternative antimalarials were influenced by patients, drug company representatives, and other providers working at the same facility and in the local area. Efforts to disseminate drug policy should target the full range of actors involved in supplying drugs, including providers, employers, suppliers and local communities.

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A strategy for reducing maternal and newborn deaths by 2015 and beyond

G Darmstadt, T Marchant, M Claeson, W Brown, S Morris, F Donnay, M Taylor, R Ferguson, S Voller, KC Teela, K Makowiecka, Z Hill, L Mangham-Jefferies, B Avan, N Spicer, C Engmann, N Twum-Danso, K Somers, D Kraushaar, J Schellenberg

BMC Pregnancy and Childbirth 2013, 13:216 | DOI: 10.1186/1471-2393-13-216


Background: Achievement of Millennium Development Goal (MDG) 4 for child survival requires acceleration of gains in newborn survival, and current trends in improving maternal health will also fall short of reaching MDG 5 without more strategic actions. We present a Maternal Newborn and Child Health (MNCH) strategy for accelerating progress on MDGs 4 and 5, sustaining the gains beyond 2015, and further bringing down maternal and child mortality by two thirds by 2030.

Discussion: The strategy takes into account current trends in coverage and cause-specific mortality, builds on lessons learned about what works in large-scale implementation programs, and charts a course to reach those who do not yet access services. A central hypothesis of this strategy is that enhancing interactions between frontline workers and mothers and families is critical for increasing the effective coverage of life-saving interventions. We describe a framework for measuring and evaluating progress which enables continuous course correction and improvement in program performance and impact.

Summary: Evidence for the hypothesis and impact of this strategy is being gathered and will be synthesized and disseminated in order to advance global learning and to maximise the potential to improve maternal and neonatal survival.

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Effectiveness of interventions to strengthen national health service delivery on coverage, access, quality and equity in the use of health services in low and lower middle income countries

B Willey, L Smith Paintain, L Mangham-Jefferies, J Car, J Armstrong Schellenberg

EPPI-Centre, Social Science Research Unit, Institute of Education, University of London, London, UK (2013) iii + 132 pp. ISBN 978-1-907345-55-5

Executive summary

Low coverage of effective and cost-effective interventions that could save lives has been partially attributed to weak and inefficient health systems, leading to the identification and promotion of health system strengthening as a global health priority. Front-line health workers are key to delivering health services, so we have assessed the effectiveness of supply-side interventions to improve their ability to deliver health services.

Key messages

Moving beyond technical guidance alone:

  • Studies which strengthened other elements of the health service delivery in addition to technical guidance, as well as community mobilisation and interventions at the health sector policy and strategic management level showed more consistent improvement on quality of care and counselling than those using technical guidance alone.

Supply-side interventions that appeared to have a positive effect on quality of care included:

  • text message reminders (with motivational quotes) for malaria case management;
  • training for malaria case management when combined with community awareness, supervision and referral mechanisms;
  • job aids for antenatal counselling when combined with supervision and a focus on institutional adaptations required to incorporate the use of these job aids;
  • IMCI (integrated management of childhood illnesses) training, when implemented in combination with enhanced supervision that incorporated training of supervisors, job aids, use of data and face-to-face supportive supervision, in repeated cycles of assessment, examination/feedback and planning;
  • implementation of guidelines, when delivered using training, enhanced supportive supervision, a focal person to troubleshoot problems on site, and repeated progress surveys with face-to-face feedback and planning sessions;
  • quality improvement, when combined with training, supervision, repeated progress surveys with time frames and named individuals identified against decisions/plans made during face-to-face meetings with all health facility staff, and district level representation;
  • implementation of full IMCI guidelines, incorporating training, supervision and discussion of how to overcome barriers to implementation, wider health system strengthening at the health sector policy and strategic management level, and community mobilisation.

Effectiveness of interventions to strengthen national health service delivery on coverage, access, quality and equity in the use of health services in low and lower middle income countries

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