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    • But in comes the good news from these three NEOVITA

    2019-05-14

    But in comes the good news from these three NEOVITA studies: there are other effective, feasible interventions that can be implemented everywhere. Rajiv Bahl and colleagues identify that early initiation of breastfeeding and exclusive breastfeeding have independent beneficial effects on neonatal mortality.
    The UN Commission on Life Saving Commodities (UNCoLSC) was established in 2012 with an explicit aim to secure a steady supply of key commodities across reproductive, maternal, newborn, and child health (RMNCH). Although late in the process of accelerating progress to reach the Millennium Development Goals, the UNCoLSC targeted securement of the supply and uptake of 13 life saving commodities in low-income and middle-income countries through various actions including market shaping, regulatory efficiency, innovative financing, demand creation, and targeting women and children at greatest risk. The evaluation by Pronyk and colleagues presents a situational and bottleneck analysis of progress in 12 of the 18 sub-Saharan African countries that received RMNCH trust funds and were evaluated from 2013 to 2015. The mixed methods approach that was used relied on a range of participants and informants, and since the evaluation was not independent, this could well have overestimated progress and readiness in some countries. These issues notwithstanding, the report details a mixed bag of progress and lack thereof. The BAY 87-2243 identified are well recognised and range from an almost universally inadequate regulatory and quality assurance environment and supply chain, to insufficient staff training and persistent stock-outs in almost half of the facilities evaluated. Of the US$200 million disbursed so far, almost 70% of the funds were spent on systems strengthening ($89 million on staff training, mentorship, and support and $53 million for district-level monitoring and evaluation). Given the early stage of implementation and procurements, the $21 million spent on community mobilisation and advocacy, a mean of $2 million per country over the last 2–3 years, seems excessive. This question of value for money is important, as only a small proportion of the funds released since 2012 have actually gone towards procuring commodities. Although establishing a framework for global consensus, establishing supply chains, and understanding bottlenecks are important, the fundamental accountability lies in ensuring that life saving commodities reach the poorest of the poor. Many of the issues identified with procurements, market shaping, systems gaps, and the balance of push and pull factors are common to the experience of the Global Fund around commodities for malaria, tuberculosis, and HIV, and the training gaps are not dissimilar. I wonder whether a more efficient and rapid review process was possible given that many of the countries targeted are also Global Fund recipients. Another key question is the nature of commodities targeted by the UNCoLSC. Although a series of technical committees provided input, the selection of specific commodities was not standardised on parameters of global evidence, consensus, and WHO recommendations. For example, although the case for deploying antenatal steroids for saving newborn lives was built through a technical review process, there were no examples of successful use of antenatal steroids among health systems in low-income and middle-income countries. The substantial adverse effects experienced in a recent multicountry study of antenatal steroids, possibly as a result of inappropriate targeting by health workers, led to a reconsideration of their use at scale before addressing key questions around implementation in health systems. This work and implementation research is led by WHO, but does question aggressive promotion of certain commodities in the absence of clear WHO guidelines and relevant safety data from low-income and middle-income countries. Similarly, findings from the 12 countries of poor community demand and facility bottlenecks for the use of emergency contraception and female condoms also raises issues of sequencing and the necessity of developing community demand and social marketing around such commodities. As suggested by Dawson and colleagues, the role of the private sector in providing emergency contraception is increasingly recognised and underscores the importance of appropriate public–private partnerships and performance enhancement strategies. There is therefore a need to revisit the issue of commodity selection, and to focus on key diagnostics and other technologies that are clearly important for saving lives but may have been ignored so far. Simple diagnostics can help save lives across the continuum of care, such as pulse oximetry, and simple technologies are essential for triaging babies at risk, such as low-cost weighing scales. One of the most important commodities in short supply in low-income and middle-income countries is oxygen, which can make the difference between saving the life of a critically ill mother or young infant. A formal gap analysis of key commodities and supply chain would greatly help in building a list of key commodities and delivery strategies.