This article describes one of the fastest and largest declines in child mortality ever reported and prompts a few reflections.

First, global health has been the subject of a great deal of fanfare in the past decade.1 This has been a boon for the field bringing attention, funding, and fresh thinking to the challenges of health equity. This trend has also created a subculture of projects, organizations, and personalities seeking to ride this wave of interest in order to raise funds or gain publicity. Much of the discussion in this arena is premised on branding and marketing in the absence of data-driven evaluation on the actual work being promoted. At the same time, there are likely important advances being made on the ground whose impact and broader lessons are missed due to lack of rigorous assessment. Johnson and colleagues’ study is a refreshing change and lets measured outcomes speak for themselves and serve as the barometer for effective practice. This matching of well-intentioned, evidence-based efforts with data-driven evaluation can hopefully prompt a greater orientation towards measured results in the global health sphere.

Second, it is noteworthy that such remarkable results were achieved not by new and innovative strategies, but through proven interventions and approaches. The core components of the deployed strategy – early case detection with community health workers (CHWs) and referral networks, establishing basic healthcare infrastructure, removing financial barriers, and broader community engagement – all reflect approaches that have been validated as ways to improve child health.2 3 4 This does not diminish the work in Yirimadjo, but, rather, elevates it. Attention is often geared towards doing something ‘new’ or ‘disruptive’ instead of effectively applying what is already known and effective.

This brings me to a third and related point. The ‘novelty’ of the work described in this study may, in fact, lie in the actual day-to-day execution of established strategies. Many places already have similar approaches laid out in policy, but do not achieve such compelling results due to weak implementation. For example, the public health system in India has one CHW designated for every 1,000 people and linked to a health post set up to provide basic maternal and child healthcare. These CHWs take on a package of tasks similar to those in this study including early detection and referral of sick children. However, in practice, this approach has not been nearly as successful.5 The work described by Johnson and colleagues suggests a pattern of reliable performance and may offer important lessons for healthcare organization, management, and implementation. How did the project assure such consistency? What approaches were used to enforce accountability of performance? What did the project do to troubleshoot breakdowns in delivery when they occurred? What of these approaches were systematized into organizational practices and which relied on the discretion of well-trained and strong managers? Understanding how this work was executed well enough to get such impressive results may offer important insights. A case study highlighting these practices would be a compelling description of an impressive effort.


Ranu S. Dhillon
Division of Global Health Equity
Brigham and Women’s Hospital
Boston, MA



References
1. Merson MH, Chapman Page K. (2009) The Dramatic Expansion of University Engagement in Global Health: Implications for U.S. Policy. Washington, DC: Center for Strategic and International Studies.

2. Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA, Zulfiqar A, et al. (2005) Community-Based Interventions for Improving Perinatal and Neonatal Health. Outcomes in Developing Countries: A Review of the Evidence. Pediatrics 115: 519–617.

3. United Nations Children’s Fund (UNICEF) (2010) Progress for Children: Achieving the MDGs with Equity. UNICEF 9: 22–23.

4. Lehmann U, Sanders D. (2007) Community health workers: what do we know about them?. World Health Organization.

5. National Health System Resource Centre. (2011) ASHA: Which way forward? Evaluation of ASHA Programme. Delhi: National Health System Resource Centre, 2011.