Integrating Safe Water and Maternal Health in Malawi. Ryan Rowe Water Institute at UNC West Africa Regional Workshop on HWTS May

Transcription

1 Integrating Safe Water and Maternal Health in Malawi Ryan Rowe Water Institute at UNC West Africa Regional Workshop on HWTS May

2 Access to Safe Water in Malawi 83% of Malawian homes have improved water but: Low functionality of water sources (39% nationally)** Rural water quality contamination (55% in wet season)*** Supply interruptions force use of unimproved sources** 17% still drink water from unimproved sources: lakes, rivers Improved water can become contaminated Unsafe collection, handling and storage Household water treatment and safe storage (HWTS) provides a means of assuring safe water until use Reduces risk of diarrhoea by up to 47%**** Sources: *WHO & UNICEF JMP Update, March **Sector Performance Report 2011; ***Taylor et al, 2012; ****Fewtrell et al, 2005; Clasen et al, 2006; Waddington et al, 2009

3 Maternal and Child Health in Malawi Malawi has high maternal and infant mortality Most women attend 1 antenatal visit (93%) but few (21%) complete 4 antenatal visits* Only 72% deliver at a health facility and timely postnatal checks are uncommon (43%)* Diarrhoea is a leading cause of child illness and death* Integrating HWTS incentives into ANC may increase safe water and hygiene behaviors and reduce morbidity and mortality by encouraging women to use health services** Source: *DHS, 2010; Sheth et al, 2010; UNICEF A Promise Renewed, 2012

4 Current status of HWTS 2002: HWTS introduced by Population Services International (PSI) 2005: National survey of 1669 mothers* 64% heard of WaterGuard 7% reported current use 2007: Integration into ANC Teachable moment 2012: National action plan Source: *Stockman et al, 2007

5 Program Implementation Free hygiene kit at first ANC visit: WaterGuard/PUR, bucket, soap and ORS Education on safe water treatment, hand-washing, family planning Free refills at subsequent visits: ANC, delivery and postnatal check Presence of husband or partner HSA education, home visits, monitoring is key link to community PSI social marketing, product distribution

6 HWTS/ANC Program piloted in Malawi 55,000 water hygiene kits distributed since districts: Blantyre, Salima, Machinga sites Blantyre & Salima 7 CBCCs Blantyre & Salima 16 health centres Machinga Handover to Machinga DHO

7 Results: ANC Service Use, Outcome of Pregnancy Malawi DHS( 2010) Participants (n=97) 4 or more antenatal visits 21% 56% Delivery at health facility 72% 90% Baby alive % 6 week post-natal check-up 50% 90% Source: CDC & CHAI, 2011; DHS, 2010

8 Results: ANC and HIV Services Pregnant women tested for HIV Women in ANC receiving ARVs 2008 (BL) 2009 (Pre-HWTS) 2010 (HWTS)* 50% 84% 85% 2% 22% 58% Delivery at a facility 15% 32% 48% HIV-exposed infants on ARV prophylaxis 0% 54% 90% Source: Data collected by CHAI from 15 clinics in Machinga District during a period in which the program was being implemented in only 8 facilities.

9 Results: WaterGuard Use Confirmed WG use (WG bottle + positive chlorine test)* Confirmed WG use AND purchase of WG* Baseline (n=106) Follow-up (n=97) 0% 69% 0% 36% No HSA visit >4 HSA visits Confirmed WG use after visits by HSAs 38% 93% * p < Source: CDC & CHAI, 2011

10 Maternal mortality in Malawi Mothers need skilled delivery in facilities Maternal mortality: 675 to 807 per 100,000 live births* Cause of death Proportion [# of deaths]** Potential mortality reduction from skilled delivery*** Hemorrhage 25% [ ] 30-50% [50-100] Sepsis 15% [ ] 50-70% [50-84] Eclampsia 12% [81-96] 20-40% [17-40] Obstructed labour 8% [54-64] 70-85% [35-51] Total 60% [ ] 16-33% [ ] Rough analysis suggests up to 278 deaths per 100,000 live births are avoidable with increased delivery at facilities of which ante-natal care is a determining factor Source: *MICS 2006 / DHS 2010; ***Guebbels, n.d.; ***Graham et al, 2001

11 Scale up to reduce maternal mortality (and reach vulnerable group with HWTS) Idea to integrate HWTS into ANC guidelines s, calls, meetings to lobby Ministry of Health Two presentations to Sub-Committee on Safe Motherhood Ministry of Health input / support to a US$2m proposal Presentation to Technical Working Group on Reproductive Health

12 Scale up to reduce maternal mortality Decision criteria for policy-makers Evidence-based: Does it really deliver health impact? Cost-effectiveness: Does it merit scarce resources? Scalability: Can it be replicated nation-wide? Sustainability: Will it be accepted by the community? Feasibility: Who will implement and are they capable? Unintended consequences: What else might happen?

13 Key partners / acknowledgements Implementation partners Ministry of Health Malawi Population Services International (PSI) Procter & Gamble s Children s Safe Drinking Water Program Clinton Health Access Initiative (CHAI) UNICEF Evaluation partners Ministry of Health Malawi US Centers for Disease Control and Prevention (CDC) PATH Clinton Health Access Initiative (CHAI) Abt Associates Donors USAID Clinton Foundation Gates Foundation

14 Zikomo kwambiri / Thank you very much The best thing antenatal care could do is to motivate women to opt for safe deliveries, i.e. deliveries assisted by trained professionals (McDonagh, 1996)

15 EXTRA SLIDES

16 How much will this program cost? About $142,000 (MK 43m) per district Est. commodity cost per participant: $5.56 Est. implementation cost per household per annum: $2.43 Est. total cost per household per annum: $7.99 Total cost for nationwide scale-up: $4,130,134 Average cost per district: $142,000 Amounts include salaries for HSAs and were calculated prior to the devaluation, thus need to be updated. Source: *PATH/Abt Analysis, 2012.

17 How does ANC/HWTS compare? Costlier but less challenging to implement Program Cost to scale nationally Cost / household member Original ANC program $4,600,000 $1.39* Current ANC program $4,100,000 $1.24* Chlorine stock solution $7,740,000** $0.52*** All figures are approximate. Key assumptions: *National cost / 660,000 pregnancies a year / 5 people per HH **Household cost of $2.58 x 3,000,000 households ***Household cost of $2.58 / 5 people per HH Cost analysis conducted when exchange rate was MK 147 to 1 USD Source: *PATH/Abt Analysis, 2012.

18 Do incentives make financial sense? Intuitively yes; CDC now evaluating Do costs of dealing with adverse maternal health outcomes outweigh cost of incentives? Intuitively, the answer is yes Benefits extend to a range of other health outcomes CDC conducting cost analysis on Machinga program Cost of cases averted Cost of DALYs saved If program creates net savings for health system, then it s more attractive than the status quo Source: Personal communication with Rob Quick/CDC, 20 August 2012.

19 Are incentives the best approach? Yes, for this program Behavioural transformation Trigger awareness of important health behaviour Allow for trial use to experience the product Support from HSAs encourages continued use Stimulates purchase of product Behaviour spread to family and friends Incentives should be: attractive to target audience cost-effective In this case, standard operating procedure for ANC

20 Is behaviour change sustainable? Yes 2007 Baseline (N=389) 2008 Follow-up (N=330) 2010 Follow-up (N=232) Confirmed WG use (WG bottle + residual chlorine) Confirmed WG use and purchase (WG bottle + residual chlorine + purchase) Demonstrate proper hand washing 2% 61% 24% 1% 32% 21% 21% 68% 50% In 2010, 54% of Blantyre/Salima households treated their water with WG or chlorine stock solution Source: Loharikar et al., in press.

21 What health outcome is the priority? Health of mother and child Survival and health of mother and child Actual quality of care / integrated service delivery HIV VCT services for couples ART enrolment if needed Ante-natal care (includes PMTCT) Family planning consultations Water-related hygiene education and receipt of kit Education on breastfeeding practices Immunisations Perceived quality of care Creates desire to use services including delivery at facility

22 Is health impact measurable? Yes Meta-analysis: HWTS reduces diarrhoea up to 47%* Haiti: 8yrs of HWTS promotion meant children in participating households 59% less likely to have diarrhoea** Malawi HMIS and IDSR collects data on diarrhoea Machinga: Diarrhoea declined 18% from 2010 to 2011*** Indirect link betw ANC & maternal/neonatal mortality Aim of ANC to screen women and link to other services At least 6 districts (>100,000 program participants) needed to measure program impact on mortality - CDC interested**** Source: *Fewtrell et al, 2005; Clasen et al, 2006; Waddington et al,, 2009; **Harshfield et al, ***Personal communication with Young Samanyika/GOM-MOH, 10 October ****Personal communication with Rob Quick/CDC, 4 October 2012.

23 Could this impact on PNC use? It seems likely New mothers should receive a PNC check-up within: 24 hours if they deliver in a health facillity 12 hours if they do not deliver in a health facility Currently no available data for the above indicators At 6 weeks: 90% of program mothers returned (n=97) Compared to 50% as reported by DHS (2010) Possibly linked to timing of immunisations

24 Could program lead to more pregnancies? Possibly but hard to say No evidence yet (neither anecdotal nor factual) This is a possible unintended consequence and should not be ignored Family planning consultations could mitigate the risk Use of FP methods actually increased 5.7% from 2010 to 2011 Qualitative evaluation could assess such behaviour