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    • Because of the above limitations of sampling based surveilla

    2019-06-29

    Because of the above limitations of sampling-based surveillance systems such as the NMNMSS, some regions have started to conduct complete birth-population-based regional surveys, which will contribute substantially to our understanding of neonatal vital statistics in China. Such surveys include all births in the registry regardless of the hospital level and subjects\' socioeconomic status. Efforts should be directed firstly to the birth populations of subprovincial regions in each province, thereafter extending to the whole province level. Step by step, we might expect to obtain birth vital statistics from a comprehensive national perspective.
    It is already reasonably well established that, with adequate coverage, the community-mobilisation approach of women\'s groups practising participatory learning and action is associated with a programmatically attractive Thioguanine in neonatal mortality in low-resource high-burden settings. In 2014, WHO recommended implementation of this intervention particularly in rural settings with low access to health services. The uncertainty, however, has been whether such an approach is actually scalable in public health programmes that are often driven by supply-side strategies. The study by Prasanta Tripathy and colleagues in this issue of helps in filling this translational gap to a significant extent. In previous studies on this approach, the women\'s group meetings (the core of the intervention) were facilitated by local women specially recruited and trained for respective research projects. In Tripathy and colleagues\' cluster-randomised trial, conducted in five districts of the two eastern states of India, these meetings were instead facilitated by government-appointed village-level female health workers, namely Accredited Social Health Activists (ASHAs) who received a token incentive for the task (US$3 per meeting). Most of the participating women were tribal, and almost half of them belonging to the lowest two wealth quintiles. After 2 years, the primary outcome of neonatal mortality rate (NMR) was significantly lower in the intervention clusters than in the control clusters (30 per 1000 livebirths 44 per 1000 livebirths, respectively; adjusted odds ratio 0·54, 95% CI 0·36–0·80). Equally impressive was the reduction in early NMR by 46% (27 per 1000 livebirths 37 per 1000 livebirths, respectively; adjusted odds ratio 0·54, 95% CI 0·35–0·84). There are three characteristics worth highlighting about this study in addition to the fact that the intervention was implemented by the public-sector health workers. First, the intervention resulted in neonatal survival dividends in a population where facility births are high (overall around 60%). Previous studies in settings with high facility birth rates were equivocal in this regard. Second, the intervention coverage (66%) was higher than that reported in earlier studies. Third, the same ASHAs who conducted the women\'s group meetings were also responsible for postnatal home visits as a part of the home-based newborn care scheme of the national government. It is quite plausible that a closer mother–ASHA rapport and better preparation for postnatal care resulting from interaction at the group meetings could have synergistically augmented the effectiveness of home-based care in the intervention group (home visiting coverage 64%). The latter two characteristics may also partly explain why the neonatal mortality reduction effect was greater than that seen in earlier studies. WHO defines a health system as “all the activities whose primary purpose is to promote, restore or maintain health”. On this basis, community engagement aimed at improving health should be a part of the health system. But the WHO framework comprising six “building blocks” of health systems (namely, service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance) excludes community participation. This is a miss. Not surprisingly, community\'s role in health promotion, generating demand for services, and ensuring accountability is sidelined or underplayed when policies are laid down and programmes implemented. There is another difficulty. Community mobilisation requires skills that are different from those needed to, say, run facilities, treat individuals, or organise immunisation sessions. Professionals who understand sociocultural–behavioural context at the bottom of the pyramid, and are able to engage people and elicit their active involvement, may not necessarily be a part of the front-line health teams. Further, emphasis laid on the indicators of community participation in the programme monitoring frameworks is often low; hence the “not measured” remains “not done” even when such approaches are, on paper, a part of the package of interventions.