Comprehensive Review of The Evidence Regarding The Effectiveness of Community

VIEWPOINTSPAPERS
journal of
health
global
Henry B Perry1,
Bahie M Rassekh2,
Sundeep Gupta3,
Jess Wilhelm1,
Paul A Freeman4,5
1 Department of International
Health, Johns Hopkins
Bloomberg School of
Public Health, Baltimore,
Maryland, USA
2 The World Bank,
Washington DC, USA
3 Medical Epidemiologist,
Lusaka, Zambia
4 Independent consultant,
Seattle, Washington, USA
5 Department of Global
Health, University of
Washington, Seattle,
Washington, USA
Correspondence to:
Henry Perry
Room E8537
Johns Hopkins Bloomberg
School of Public Health
615 North Wolfe St.
Baltimore, MD 21205
USA
[e-mail]
Comprehensive review of the evidence regar
effectiveness of community–based primary h
care in improving maternal, neonatal and chi
1. rationale, methods and database descripti
Background Community–based primary health care (CBPHC) is an approach u
health programs to extend preventive and curative health services beyond hea
into communities and even down to households. Evidence of the effectiveness o
in improving maternal, neonatal and child health (MNCH) has been summarized
ers, but our review gives gives particular attention to not only the effectiveness
interventions but also their delivery strategies at the community level along wit
uity effects. This is the first article in a series that summarizes and analyzes the
of programs, projects, and research studies (referred to collectively as projects)
CBPHC to improve MNCH in low– and middle–income countries. The review add
the following questions: (1) What kinds of projects were implemented? (2) Wha
outcomes of these projects? (3) What kinds of implementation strategies were u
What are the implications of these findings?
Methods 12 166 reports were identified through a search of articles in the Nat
of Medicine database (PubMed). In addition, reports in the gray literature (avail
but not published in a peer–reviewed journal) were also reviewed. Reports that
the implementation of one or more community–based interventions or an integ
ect in which an assessment of the effectiveness of the project was carried out q
inclusion in the review. Outcome measures that qualified for inclusion in the rev
population–based indicators that defined some aspect of health status: changes
tion coverage of evidence–based interventions or changes in serious morbidity,
tional status, or in mortality.
Results 700 assessments qualified for inclusion in the review. Two independen
completed a data extraction form for each assessment. A third reviewer compa
data extraction forms and resolved any differences. The maternal interventions
cerned education about warning signs of pregnancy and safe delivery; promotio
provision of antenatal care; promotion and/or provision of safe delivery by a tra
tendant, screening and treatment for HIV infection and other maternal infection
planning, and; HIV prevention and treatment. The neonatal and child health inte
that were assessed concerned promotion or provision of good nutrition and imm
promotion of healthy household behaviors and appropriate utilization of health
agnosis and treatment of acute neonatal and child illness; and provision and/or
of safe water, sanitation and hygiene. Two–thirds of assessments (63.0%) were
implementing three or fewer interventions in relatively small populations for rel
periods; half of the assessments involved fewer than 5000 women or children, a
of the assessments were for projects lasting less than 3 years. One–quarter (26
projects were from three countries in South Asia: India, Bangladesh and Nepal.
of reports has grown markedly during the past decade. A small number of fund
ed most of the assessments, led by the United States Agency for International D
The reviewers judged the methodology for 90% of the assessments to be adequ
Conclusions The evidence regarding the effectiveness of community–based in
to improve the health of mothers, neonates, and children younger than 5 years
growing rapidly. The database created for this review serves as the basis for a s
cles that follow this one on the effectiveness of CBPHC in improving MNCH publ
the Journal of Global Health. These findings, guide this review, that are included
paper in this series, will help to provide the rationale for building stronger comm
based platforms for delivering evidence–based interventions in high–mortality,
constrained settings.
Electronic supplementary material:
The online version of this article contains supplementary material.
www.jogh.org • doi: 10.7189/jogh.07.010901 1 June 2017 • Vol. 7 No. 1 • 010901

VIEWPOINTSPAPERS
Perry et al.
The evidence that community–based interventions can improve maternal, neonatal and child
(MNCH) has been steadily growing over the past several decades [1–3]. Nonetheless, comm
primary health care (CBPHC) as an approach for engaging communities and delivering healt
tions to communities and even down to each household remains an underdeveloped compon
systems in most resource–constrained settings. Except for immunizations and vitamin A sup
tion, population coverage levels of evidence–based MNCH interventions in the countries with
world’s maternal, neonatal and child deaths remains around 50% or less [4]. The evidence r
effectiveness of individual interventions provided at the community level continues to grow.
stand in a moment of time in which the era of the United Nations’ Millennium Development G
ended (2000–2015) and the era of the Sustainable Development Goals has begun (2015–203
now is an opportune time to take stock of the evidence regarding the effectiveness of comm
approaches in improving MNCH and the approaches that have been used to achieve effectiv
Even though major gains have been made around the world in reducing maternal, neonatal,
mortality (MNCH), 8.8 million maternal deaths, stillbirths, neonatal deaths, and deaths of chi
months of age occur each year, mostly from readily preventable or treatable conditions [5].
the 75 countries with 97% of the world’s maternal, perinatal, neonatal and child deaths were
achieve both Millennium Development Goal (MDG) 4 (which called for a two–thirds reduction
der–5 mortality by the year 2015 compared to 1990 levels) and MDG 5 (which called for a th
ters reduction of maternal mortality) [6]. One of the important reasons for this disappointing
the failure to implement and scale up evidence–based community–based interventions.
To date, there has been limited attention given to systematically accumulating and analyzin
range of evidence regarding the effectiveness of CBPHC in improving MNCH, although excel
maries of portions of this evidence do exist [1–3,7–17]. In addition, there appears to be a reb
al primary health care more generally, especially in light of the upcoming 40th anniversary of the signing
of the Declaration of Alma–Ata at the International Conference on Primary Health Care at Alm
zakhstan in 1978, sponsored by the World Health Organization and UNICEF [18]. This article
of a series that highlights the findings of a comprehensive review and analysis of this eviden
and middle–income countries (LMICs).
The context
The global primary health care movement began in the 1960s following the recognition that
were not improving the health of the populations they were serving. At that time, a series of
populations served by hospital–oriented Christian medical mission programs around the wor
strated that the people who had easy access to and used the hospital regularly were no hea
people who did not [19]. This led to the formation of the Christian Medical Commission (CMC
World Council of Churches, which provided a framework and a forum for new thinking about
grams can best improve the health of people in high–mortality, resource–constrained setting
1970s, these discussions involved global health visionaries of their time, including Dame Nit
Jack Bryant, Carl Taylor, and William Foege, all of whom were members of the CMC, and high
ficials at the World Health Organization (WHO), including Halfdan Mahler, then Director–Gen
Ken Newell, Director of Strengthening of Health Services at WHO [20,21]. One of the fruits o
cussions was the seminal WHO publication, Health by the People [22]. This book described a
successful pioneering CBPHC projects around the world and laid the groundwork for the 197
tional Conference on Primary Health Care at Alma–Ata, Kazakhstan and the now renowned D
of Alma–Ata, which called for Health for All by the Year 2000 through primary health care [2
Article V of the 1978 Declaration of Alma–Ata states the following [24]:
“Governments have a responsibility for the health of their people that can be fulfilled only b
equate health and social measures. A main social target of governments, international organ
world community in the coming decades should be the attainment by all peoples of the worl
a level of health that will permit them to lead a socially and economically productive life. Pri
the key to attaining this target as part of development in the spirit of social justice.”
The broad concept of primary health care articulated in this Declaration was much more tha
ery of medical services at primary health care centers. Primary health care, as defined by th
of Alma–Ata, involves providing preventive, promotive, curative, and rehabilitative health ca
as close to the community as possible by members of a health team, including community h
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VIEWPOINTSPAPERS
CBPHC, rationale, methods and database descrip
ers and traditional practitioners, and it broadened the concept even further by calling for p
care to also address the primary causes of ill–health through inter–sectoral collaboration, c
ticipation, and reduction of inequities.
Over the past three decades since the Declaration of Alma–Ata, major progress has been m
ing child and maternal mortality throughout the world. The number of children dying befor
age has declined from 18.9 million in 1960 [25] to 5.9 million in 2015 [26] despite the fact
ber of births each year has increased from 96 million in 1960 [25] to 139 million in 2015 [2
al under–5 mortality rate has declined from 148 per 1000 live births in 1970 [25] to 43 in 2
Over the past 25 years, the global under–5 mortality rate globally has fallen by 53% [26], f
the 67% required to reach the Millennium Development Goal for 2015. Reductions in mate
ity have also been important but more gradual. The number of maternal deaths declined fr
in 1990 to 303 000 in 2015 [28], and the global maternal mortality ratio fell by 44% during
[28], far less than the 75% required to achieve the Millennium Development Goal.
Although evidence about the effectiveness of specific community–based interventions is ge
documented, evidence about the total range of CBPHC interventions for MNCH, their effect
these interventions are actually delivered in practice (particularly in combination with othe
tions), and the conditions that appear to be important for achieving success are less summ
the heart of what our review is about.
Our review begins with the premises that (1) further strengthening CBPHC by expanding th
coverage of evidence–based interventions has the potential to accelerate progress in endin
child and maternal deaths, and (2) CBPHC has the potential for providing an entry point for
a more comprehensive primary health care system in resource–constrained settings that c
systems to more effectively improve population health and, at the same time, more effecti
needs and expectations of local people for medical care.
There is now, more than ever, a need for evaluation of what works and for “systematic sha
practices and greater sharing of new information” [29]. As an editorial in The Lancet [30] o
“Evaluation must now become the top priority in global health. Currently, it is only an after
scale–up in global health investments during the past decade has not been matched by an
evaluation…. [Evaluation] will not only sustain interest in global health. It will improve qual
ing, enhance efficiency, and build capacity for understanding why some programmes work
Evaluation matters. Evaluation is science.”
This series provides an opportunity to summarize, review and analyze the evidence regard
tiveness of CBPHC in improving the health of mothers and their children, to draw conclusio
the findings from this review, and to suggest next steps in research, policy and program im
Background of the review
In the early 1990s, Dr John Wyon (now deceased) and Dr Henry Perry organized panels at t
meetings of the American Public Health Association (APHA) to highlight the contributions o
improving the health of geographically–defined populations. As a result of support and enc
from the International Health Section at APHA and from APHA staff, a Working Group on CB
the International Health Section was established in 1997. For two decades now, the Workin
been holding day–long annual workshops on themes related to CBPHC. One of these works
the publication of a book on CBPHC [31]. As the evidence continued to mount regarding th
of CBPHC in improving health, the Working Group decided that a comprehensive review wa
Thus, beginning in 2005, the Working Group created a Task Force for the Review of the Ev
PHC in Improving Child Health, with Henry Perry and Paul Freeman serving as Co–Chairs. W
as a small volunteer effort by Perry and Freeman and others has now, more than a decade
over 150 people and not only APHA but also the World Health Organization, UNICEF, the W
the US Agency for International Development, Future Generations (the NGO where Dr Perr
ployed at the outset of the review), and most recently the Gates Foundation.
Following an initial small grant from the World Health Organization in 2006, an Expert Pane
ated under the chairmanship of Dr Carl Taylor, then Professor Emeritus of International He
Johns Hopkins University (Table 1). This group participated in the initial design of the revie
later met face to face at UNICEF Headquarters in 2008 to discuss preliminary findings of th
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Table 1.Members of the Expert Panel for the Review of the Effectiveness of Community–Based Primary Health Care in
Maternal, Neonatal and Child Health
Name OrgaNizatiONalaffiliatiON title lOcatiON ParticiPatediN
fOrmalizatiONOf
guideliNesfOr
review2006
ParticiPatediN
face–tO–face
meetiNgOf
PaNeliN 2008
ParticiPated
iNreviewOf
fiNalfiNdiNgs
(2016)
Raj Arole Jamkhed Comprehensive Rural
Health Project
Director (now deceased) Jamkhed,
India
X
Shobha AroleJamkhed Comprehensive Rural
Health Project
Director Jamkhed,
India
X
Rajiv Bahl World Health Organization Medical Officer, Child and Adoles-
cent Health and Development Unit
Geneva,
Switzerland
X
Abhay Bang Society for Education, Action and
Research in Community Health
(SEARCH)
Director Gadchiroli,
India
X X X
Al Bartlett United States Agency for Interna-
tional Development
Formerly Senior Advisor for Child
Survival, USAID; now retired
Washing-
ton, DC,
USA
X
Zulfiqar
Bhutta
Centre for Global Child Health,
Hospital for Sick Children, Toronto,
Canada and Center of Excellence in
Women and Child Health, the Aga
Khan University, Karachi, Pakistan
Professor Toronto,
Canada and
Karachi,
Pakistan
X
Robert Black*Bloomberg School of Public Health,
Johns Hopkins University
Professor, Department of Internation-
al Health
Baltimore,
MD, USA
X X X
Mushtaque
Chowdhury
BRAC Formerly Dean of the James Grant
School of Public Health; currently
Deputy Director
Dhaka,
Bangladesh
X
Anthony
Costello
World Health Organization Formerly Professor, International
Perinatal Care Unit, Institute of Child
Health, University College, London;
currently Director, Department of
Maternal, Newborn, Child and
Adolescent Health
Geneva,
Switzerland
X
Dan Kaseje Tropical Institute of Community
Health and Development
Director Kisumu,
Kenya
X X X
Betty
Kirkwood
London School of Hygiene and
Tropical Medicine
Public Health Intervention Research
Unit, Professor of Epidemiology and
International Health
London,
England
X X
Rudolph
Knippenberg
UNICEF Senior Advisor for Health New York,
NY, USA
X X
Nazo
Kureshy
United States Agency for Interna-
tional Development
Team Leader, Child Survival and
Health Grants Program, Bureau for
Global Health
Washing-
ton, DC,
USA
X X
Claudio
Lanata
Instituto de Investigation Nutricio-
nal
Senior Researcher Lima, Peru X X X
Adetokunbo
Lucas
Harvard University Adjunct Professor of
International Health
Ibidan,
Nigeria
X X
James PhillipsMailman School of Public Health,
Columbia University
Professor New York,
NY, USA
X X X
Pang Ruyan School of Public Health, Peking
University
Visiting Professor and formerly
National Coordinator for China,
WHO Global Survey on Maternal
and Perinatal Health
Beijing,
China
X X
David
Sanders
School of Public Health, University
of Western Cape
Professor and Dean emeritus Cape Town,
South
Africa
X X
Agnes SoucatWorld Health Organization Formerly Lead Economist, Human
Development, Africa Region of the
World Bank and currently Director of
Health Systems, Governance and
Financing of the World Health
Organization
Geneva,
Switzerland
X
Carl Taylor† Bloomberg School of Public Health,
Johns Hopkins University
Professor Emeritus, Department of
International Health (now deceased)
Baltimore,
MD, USA
X X
Mary Taylor Independent consultant Formerly Senior Program Officer,
Community Health Solutions, the
Gates Foundation and currently
Independent Senior Technical Expert
South
Royalton,
Vermont,
USA
X X X
Cesar VictoraFederal University of Pelotas Professor of Epidemiology Pelotas,
Brazil
X X
Zonghan ZhuCapital Institute of Pediatrics and
China Advisory Center for Child
Health, Beijing; Chinese Preventive
Medicine Association
Professor, Capital Institute of
Pediatrics and China Advisory Center
for Child Health, Beijing, and
Chairman of Child Health, Chinese
Preventive Medicine Association
Beijing,
China
X X X
*Chair of the Panel, 2010 to present.
†Chair of the Panel, 2006–2010.
Perry et al.
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ter Dr Taylor’s death in 2010, the Panel reconvened under the leadership of Dr Robert Blac
International Health at Johns Hopkins, and has participated in the final set of recommendat
stitute the final article in this series [32].
When the review began in 2006, the focus was exclusively on child health (that is, the hea
in their first 5 years of life). With support from USAID and the Gates Foundation between 2
it became possible to expand the scope of the review to maternal health. Thus, we have no
overall effort a review of the effectiveness of CBPHC in improving MNCH.
Goals of the review
The goal of this review is to summarize the evidence regarding what can be achieved thro
nity–based approaches to improve MNCH. The health of mothers, neonates and children as
outcome is defined here for our purposes as the level of mortality, serious morbidity, nutrit
or coverage of proven interventions for mothers, neonates and children in a geographically
ulation. The review focuses on interventions and approaches that are carried out beyond t
health facilities that serve populations of mothers, neonates and children living in geograp
areas.
The review consists of an analysis of documents describing research studies, field projects
(collectively referred to in this series as projects) that have assessed the impact of CBPHC
together, the findings comprise a comprehensive overview of the global evidence in using
prove MNCH. In addition, the review describes the strategies used to deliver community–b
tions and the role of the community and community health workers in implementing these
In addition, the review seeks to understand the context of the projects – where they were i
and by whom, where the funding came from, for how long, what size of population was ser
project, and what additional contextual factors might have influenced the project outcome
the methodological quality of the assessment.
The questions which the review seeks to answer are:
• How strong is the evidence that CBPHC can improve MNCH in geographically defined po
sustain that improvement?
• What specific CBPHC activities improve MNCH?
• What conditions (including those within the local health system) facilitate the effectivene
and what community–based approaches appear to be most effective?
• What characteristics do effective CBPHC activities share?
• What program elements are correlated with improvements in child and maternal health?
• How strong is the evidence that partnerships between communities and health systems
order to improve child and maternal health?
• How strong is the evidence that CBPHC can promote equity?
• What general lessons can be drawn from the findings of this review?
• What additional research is needed?
• How can successful community–based approaches for improving MNCH be scaled up to
national levels within the context of serious financial and human resource constraints?
• What are the implications for local, national and global health policy, for program implem
for donors?
METHODS
The Task Force and the Expert Panel agreed on the following definition of CBPHC:
CBPHC is a process through which health programs and communities work together to imp
and control disease. CBPHC includes the promotion of key behaviors at the household leve
the provision of health care and health services outside of health facilities at the communi
can (and of course should) connect to existing health services, health programs, and healt
at static facilities (including health centers and hospitals) and be closely integrated with th
CBPHC, rationale, methods and database descrip
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CBPHC involves improving the health of a geographically defined population through outreac
of health facilities. CBPHC does not include health care provided at a health facility unless th
munity involvement and associated services beyond the facility.
CBPHC also includes multi–sectoral approaches to health improvement beyond the provision
services per se, including programs that seek to improve (directly or indirectly) education, in
trition, living standards, and empowerment.
CBPHC programs may or may not collaborate with governmental or private health care prog
may be comprehensive in scope, highly selective, or somewhere in between; and they may
part of a program which includes the provision of services at health facilities.
CBPHC includes the following three different types of interventions:
• Health communication with individuals, families and communities;
• Social mobilization and community involvement for planning, delivering, evaluating and u
services; and
• Provision of health care in the community, including preventive services (eg, immunizatio
tive services (eg, community–based treatment of pneumonia).
Types of assessments of maternal, neonatal and child health interve
qualifying for review
The Task Force sought documents that described community–based programs, projects and
studies that carried out assessments of changes in MNCH indicators in such a way that any c
served could reasonably be attributed to CBPHC program interventions. At least one of the f
come indicators was required to be present in order for the assessment to be included in the
Maternal health
• Change in the population coverage of one or more evidence–based interventions (utilizati
tal care, delivery by a trained attendant, delivery in a health facility, clean delivery, and po
• Change in nutritional status
• Change in the incidence or in the outcome of serious, life–threatening morbidity (such as
sia, eclampsia, sepsis, hemorrhage); or,
• Change in mortality.
Neonatal and child health
• Change in the population coverage of one or more evidence–based interventions (clean d
propriate care during the neonatal period; appropriate infant and young child feeding, inclu
propriate breastfeeding; immunizations; vitamin A supplementation; appropriate preventio
ia with insecticide–treated bed nets and intermittent preventive therapy; appropriate hand
appropriate treatment of drinking water, appropriate sanitation; appropriate treatment of p
diarrhea and malaria;
• Change in nutritional status (as measured by anthropometry, anemia, or assessment of m
deficiency);
• Change in the incidence or in the outcome of serious but non–life–threatening morbidity (
choma, which can result in blindness);
• Change in the incidence or in the outcome of serious, life–threatening morbidity (such as
diarrhea, malaria, and low–birth weight); or,
• Change in mortality (perinatal, neonatal, infant, 1–4–year, and under–5 mortality);
In addition, the review included an analysis of available documentation concerning the degre
improvements in child health obtained by CBPHC approaches were equitable.
Document retrieval
The principal inclusion criteria for the literature review were: (1) a report describing the CBP
for a defined geographic population and (2) a description of the findings of an assessment o
effect on maternal, neonatal or child health as defined above. The focus was on the effective
gram interventions on the health of all mothers and/or children in a geographically defined a
Perry et al.
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in some cases (eg, in studies of maternal–to–child
HIV transmission), the focus was on a subset of
mothers and their children in a geographically de
fined area.
Key terms for “maternal health,” “child health
“community health,” and “developing countries”
related terms were identified to create a search q
(see Tables S1 and S2 in Online Supplementary
Document). The United States National Library o
Medicine’s PubMed database was searched period
cally up until 31 December 2015 using these two
queries, yielding 7890 articles on maternal health
and 4276 articles on neonatal or child health (Fig
ure 1). The articles were screened separately by
members of the study team. Assessments of the e
fectiveness of CBPHC in which the outcomes were
improvements in neurological, emotional or psych
logical development of children were not included
unless the reports also included one or more of th
other neonatal or child health outcome measures
mentioned above.
In addition to the PubMed search, broadcasts wer
sent out on widely used global health listservs, in
cluding those of the Global Health Council, the
American Public Health Association, the Collabora
tion and Resources Group for Child Health (the
CORE Group), the World Federation of Public
Health Associations, and the Association of Schoo
of Public Health asking for information about docu
ments, reports, and published articles which migh
qualify for the review. Finally, the Task Force con-
tacted knowledgeable persons in the field for their suggestions for documents to be includ
members of the Expert Panel. Documents not published in peer–reviewed scientific journal
cluded if they met the criteria for review, if they provided an adequate description of the in
and if they had a satisfactory form of evaluation. A total of 152 assessments met the criter
ternal health review and 548 for the neonatal/child health review (Figure 1).
Table S3 in Online Supplementary Document contains a bibliography with the referenc
with these 700 assessments. The bibliography also indicates which references were in the
review, in the child health review (and which of these were included in the analyses for ne
and child health), and the equity review. There are a number of cases in which a single ass
database is derived from more than one document. All of these references are included in
phy. Thus, when in Figure 1 above we refer to the number of articles/reports, there are a
of cases in which we have combined the various articles/reports associated with a single a
counted this as only one assessment.
Of the 33 maternal health assessments and the 115 neonatal/child health assessments inc
view that were not identified through PubMed, most (16 and 80, respectively) were project
of child survival projects funded by the USAID Child Survival and Health Grants Program an
mented by US–based non–governmental organizations. These are listed separately in Table
Supplementary Document. Other assessments that were not identified through PubMed
tions from other sources, books, or book chapters.
The document review process
Two data extraction forms were prepared through an iterative process. The extraction form
child health assessments and the form for maternal health assessments were identical exc
terventions carried out. These forms are contained in Appendices S5 and S6 in Online Sup
Figure 1.Selection process of assessments of the effectiveness of commu-
nity-based primary health care (CBPHC).
CBPHC, rationale, methods and database descrip
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VIEWPOINTSPAPERS
Document. Both forms were developed with the purpose of extracting all possible informat
regarding how the interventions were implemented at the community level and what the rol
munity was in implementation.
Two independent reviewers each completed a Data Extraction Form for each assessment th
for the review. A third reviewer provided quality control and resolved any difference observe
reviews, and the final summative review was transferred to an EPI INFO database (version 3
Info, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA). The names of th
ers, many of whom worked on a volunteer basis, are shown in the acknowledgment section;
and professional titles are contained in Table S7 in Online Supplementary Document.
Comment on terminology used
The assessments included in our review were carried out for field studies, projects, and prog
employed one or more CBPHC interventions for improving maternal, neonatal and/or child h
is a heterogeneous group of assessments in the sense that they range from (1) research rep
the efficacy of single interventions over a short period of time in a highly supervised and we
field setting to (2) assessments of programs which provided a comprehensive array of health
opment programs over a long period of time in more typical field setting. When referring to
of community–level activities as a whole, they should properly be referred to as “research st
projects/programs” but for practicality’s sake we will refer to them throughout this series sim
ects,” and the evaluations of their effectiveness as “assessments.”
Database description
An electronic database describing 700 assessments of the effectiveness of CBPHC in improv
was queried using EPI INFO version 3.5.4 and STATA version 14 (StatCorp LLC, College Statio
USA). For the purpose of this review, the 39 assessments with both maternal and child healt
have been counted as separate assessments in our analysis. Overall, 78.8% of assessments
articles published in peer–reviewed journals, 4.0% are some other type of publication (mostl
reports not available on the internet), and 12.7% are either from the gray literature (availab
ternet) or unpublished project evaluations.
Over three–fourths (78.4%) of the assessments included in our review were carried out in ru
at least in part, while 16.9% and 11.1% were carried out exclusively in an urban or peri–urba
respectively.
Among the 700 assessments in our data set, a small proportion contained data from more th
try. Thus, altogether, 786 country–specific assessments were identified. India, Bangladesh, a
the largest number of assessments (86, 77, and 47, respectively). 49.0% of the country–spe
ments came from Africa WHO Region, 28.5% from the South–East Asia Region, and 9.7% fro
icas (Table 2 and Table S8 in Online Supplementary Document). 8.6% of reports assess
in a single community, 38.1% in a set of communities not encompassing an entire health dis
province), 37.5% at the district (or sub–province) level, 7.5% at the provincial/state level, 3.7
tional level, and 3.2% at a multinational level.
The implementing and facilitating organizations for these projects were primarily private ent
universities and research organizations), often working with governments at the national, pr
local level (Table 3). While communities were — by definition — involved in all of these proj
only 4.3% of assessments were local communities the only identified implementers. Those w
implemented projects at the local level were community health workers (CHWs), local comm
bers, research workers, and government health staff.
Half (49.3%) of the assessments are of projects serving 5000 or fewer women and children.
assessments are based on data derived from projects reaching more than 25 000 women an
61.9% of the projects had begun since 2000. Almost half (46.3%) of projects were less than
duration and almost two–thirds (62.9%) were implemented for less than 3 years. Among the
and child health assessments, 51.6% were of only one intervention, and 87.4% were of four
terventions. On the other hand, among the maternal health assessments three–quarters (75
ed five or more interventions.
Our review includes 16 assessments of projects that were completed before 1980. The earlie
scribes the health impact of an integrated primary health care project in South Africa led by
Perry et al.
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VIEWPOINTSPAPERS
in the 1940s and published in 1952 [33]. The next earliest report concerns the effectivenes
toxoid immunization in Columbia, South America, published in 1966 [34].
Number of assessments completed ove
time
There has been a rapid growth in the number of asse
ments published between 1980 and 2015, but partic
larly in the period 2001–2011, the decade following t
establishment of the Millennium Development Goals
(MDGs) (Figure 2). The surge in publications is pres
both for maternal and for child/neonatal health studi
(data not shown). In the five years from 2011 until th
end of 2015 when the assessment retrieval ended, t
was a slight decline in the number of publications.
Types of outcomes assessed
We identified a total of 239 outcomes measured in t
700 assessments included in the review: 56 materna
outcomes and 183 neonatal/child outcomes (see Tab
S7 and S8 in Online Supplementary Documen
Table 2.Number of assessments of the effectiveness of community–based primary health care in impr
maternal, neonatal and child health by region and the countries with the greatest number of assess
wHO regiON Number % (N = 786)* cOuNtry Number % (N = 786)*
Africa 385 49.0% India 86 10.9
South–East Asia 224 28.5% Bangladesh 77 9.8
Americas 76 9.7% Nepal 47 6.0
Eastern Mediterranean 61 7.8% Ghana 36 4.6
Western Pacific 37 4.7% Pakistan 35 4.5
Europe 4 0.5% Uganda 34 4.3
Total 786* 100.0% Tanzania 30 3.8
Ethiopia 28 3.6
Kenya 27 3.4
Malawi 19 2.4
*The total number of countries listed here exceeds the number of assessments because some assessments were
tiple countries.
Table 3.Implementers of projects for improving MNCH
Number % (N = 700)
Facilitating and/or stakeholder organization:
State or national government 424 60.6
International NGO 281 40.1
Private organization/university/research organization 254 36.3
Local government 243 34.7
Local NGO 125 17.9
National NGO 85 12.1
Faith–based organization 27 3.9
Implementers at the community level:
Community health workers (either paid or volunteer) 519 74.1
Research workers only for the project 238 34.0
Ministry of health worker or other government–paid health workers/professionals304 43.4
Local community members (not trained as a CHW) 200 28.6
Expatriates 33 4.7
*Percentages add up to more than 100% because projects often utilized more than one Implementer.
Figure 2.Number of assessments in data set by year of publication
(in 5-year intervals).
CBPHC, rationale, methods and database descrip
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VIEWPOINTSPAPERS
Common maternal health outcomes were changes in: mortality, receipt of antenatal care, at
delivery by a skilled provider, facility delivery, care for obstetric emergencies, receipt of nut
plements, receipt of tetanus toxoid vaccination, receipt of post–partum family planning, kno
safe birth practices, and screening for HIV and other sexually transmitted infections during p
Common neonatal and child health outcomes were: changes in mortality, serious morbidity,
status, population coverage of healthy behaviors, and changes in the appropriate utilization
vices. In addition, some assessments contained outcome measures that did not qualify for th
were included with other indicators that did qualify for the review. These include progress in
tor development, changes in health–related knowledge among parents and caretakers, qual
munity case management of acute childhood illness provided by CHWs, and measures of im
in health system capacity.
Types of research methodologies used to assess effectiveness
In the majority (61.0%) of the assessments, a control or comparison group was present. In a
fourths (72.5%), pre– and post–intervention data were collected. In 44.6% of the assessmen
from a comparison group as well as pre– and post–intervention data were present. Randomi
assessment designs were present in 33.7% of the assessments. 27.4% of the assessments w
trolled before–after assessment designs. Reviewers considered the methodology to be adeq
of the assessments, and they considered the assessment quality to be good, high, or except
of the assessments.
Source of financial support for assessments
The United States Agency for International Development (USAID) was far and away the large
financial support for the assessments included in our review, contributing to the financial su
third (33.4%) of the assessments included in the review. UNICEF supported the next largest
assessments (15.8%), followed by the World Health Organization (14.2%), the Gates Founda
other UN agencies (7.7%), and the World Bank (6.2%) (Table 4). There were numerous othe
that funded a smaller number of assessments. In most (but not all) cases, the donor funded
as well as the assessment.
Availability of the database for further analyses and potential furthe
development of the database
We are not aware of any other similar database in existence. It serves as the basis for the su
ticles in this series [32,35–40]. However, there is an opportunity for more analyses of the da
is reported in this series. Any of the project assessments included in this review are availabl
with anyone who is interested (contact Henry Perry at [e-mail]).
The potential exists for maintaining this as a dynamic database that is regularly updated and
available. And, the potential also exists for expanding this database beyond MNCH to include
nity–based approaches to other global health priorities such as HIV, tuberculosis, malaria, an
diseases.
Table 4.Leading sources of financial support for projects whose assessments were included in the datab
dONOr NumberOf PrOjects/as-
sessmeNtssuPPOrted
% (N = 700)*
US Agency for International Development 233 33.3
UNICEF 110 15.7
World Health Organization (including the Pan American Health Organization)99 14.1
The Bill and Melinda Gates Foundation 75 10.7
Other UN agency (eg, UNDP, UNFPA, UNHCR, WFP) 54 7.7
World Bank 43 6.1
Department for International Development (UK) 28 4.0
Canadian International Development Agency (CIDA) 23 3.3
Wellcome Trust 18 2.6
*Multiple funders may have supported a single project/assessment.
Perry et al.
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VIEWPOINTSPAPERS
Limitations of the review
Our review is a comprehensive one, but we make no claim that it is a complete or systema
sources and time constraints prevented screening other electronic databases beyond PubM
that met the inclusion criteria. In addition, the USAID Child Survival and Health Grants prog
archive of more than 400 unpublished child survival project evaluations that meet the crite
sion and are publicly available, but resource and time constraints were such that only one–
these could be included in our review. Since the data analysis and write up portion of this s
we have identified several additional articles that would have qualified for the review. How
these would have changed the overall findings of our review.
This review is limited to documents that describe the impact of project interventions. As is
program failures and serious challenges encountered in program implementation are rarel
open–access documents or in the scientific literature. This means that a serious publication
ent and should be recognized. Nonetheless, the inability to document these experiences d
from the value of the numerous assessments that have been included in our review that d
fectiveness of CBPHC in improving MNCH.
The degree to which the assessments included in our review represent efficacy assessmen
to effectiveness assessments is an important issue which we are not able to adequately ex
assessments, of course, are carried out for projects that have been implemented under ide
es, when field staff members have optimal training, supervision, resources, and logistical s
when optimal community engagement has been established. These are conditions that oft
cur in routine settings. Effectiveness assessments, in contrast to efficacy assessments, are
der “real world” conditions. Our data extraction form did not collect information on this iss
fact, it is often difficult to determine exactly where a project might lie on a continuum betw
points. But it is the case that very few of the assessments in our database were of projects
mented without some type of international donor support or technical assistance. Thus, the
not representative of the effectiveness of current day–to–day practice of CBPHC but rather
been achieved in special circumstances in which documentation of effectiveness was unde
which presumably extra efforts had been made to assure the highest quality of implement
under the circumstances.
The degree to which these projects improved MNCH depended on many factors: the type(s
of interventions implemented, the quality of implementation, and myriad contextual factor
course, the type of outcome indicator(s) employed is important as well. Given the heteroge
the types of interventions implemented, (2) the manner in which they were implemented,
outcome measures used to assess outcomes, it is difficult to make definitive statements ab
of the evidence, about the magnitude of effect for any specific intervention, or about the e
one specific approach to implementation compared to another. Rather, the aim of our stud
the broad scope of evidence related to the effectiveness of CBPHC in improving MNCH and
clusions about the overall effectiveness of CBPHC, the most common strategies used in im
and the potential for further strengthening of CBPHC to improve MNCH globally.
It is well–known that the use of family planning, birth spacing, and the reduction of unmet
ily planning all have favorable benefits for MNCH. Furthermore, the evidence on the effecti
PHC in increasing the coverage of family planning services is extensive. Thus, inclusion of
would have made our review more complete, but time and resources were not sufficient to
Finally, our review has not included the effectiveness of CBPHC in reducing miscarriages an
This topic is an important one but time and resources were not sufficient to carry this out e
Subsequent articles in this series
Seven subsequent articles are being published in this series that answer the questions pos
These include: (i) an analysis of the effectiveness of CBPHC in improving maternal health [
analysis of the effectiveness of CBPHC in improving neonatal health [36], (iii) an analysis o
ness of CBPHC in improving child health [37], (iv) an analysis of the effectiveness of CBPHC
ing equitable improvements in child health [40], (v) the strategies employed by effective C
for achieving improvements in MNCH [38], (vi) an analysis of the common characteristics o
projects with long–term evidence of effectiveness in improving MNCH [39], and (vii) summ
ommendations of the Expert Panel [32].
CBPHC, rationale, methods and database descrip
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VIEWPOINTSPAPERS
CONCLUSIONS
An extensive database of the evidence regarding the effectiveness of CBPHC in improving M
been assembled. Special attention has been given to how projects were implemented at the
level. The articles that follow in this series describe the findings of analyses of this database
conclusions and recommendations of an Expert Panel. The aim of this series is to contribute
mulation of policies and programs that will be useful for ending preventable maternal, neona
deaths and for achieving universal access to care for women and their children by the year 2
strengthening CBPHC.
Acknowledgments: We are grateful to the following organizations that provided small grants to cov
penses of this review: UNICEF, the World Bank, the Department of Child and Adolescent Health and D
ment of the World Health Organization, the CORE Group (Collaboration and Resources for Child Healt
Future Generations, and the Gates Foundation. We are also grateful to the American Public Health As
and particularly its International Health Section staff, which administered some of these funds. We th
Generations for providing office space, administrative support, and salary support to Dr Perry during
phase of the review. The World Bank made it possible for one of its consultants, Dr Bahie Rassekh, to
as a member of the Study Team. We thank the following people for serving as reviewers of assessme
Adhikari, Asma Aftab, Azal Ahmadi, Iain Aitken, Laura Altobelli, Chidinma Anakwenze, Ramin Asgary,
worth Hill, Gretchen Berggren, Warren Berggren, Claire Boswell, Lisa Bowen, Amberle Brown, Jack Bry
raci Cesar, Elizabeth Chan, Stephanie Chang, Elizabeth Cheatham, Ketan Chitnis, Len Christie, Deann
Christine Davachi, Jean Richard Dortonne, Duane Dowell, Ashkan Emami, Sheila Enoh, Qi Fan, Meredi
Paul Freeman, Asha George, Juliana Grant, Stacy Grau, Sundeep Gupta, Nancy Habarta, Nowreen Haq
Paymon Hashemi, Ann Hershberger, Zelee Hill, Sandy Hoar, Asim Jani, Dennis Kim, Woon Cho Kim, Aj
mar, Stacy Laswell, Ramiro Llanque, Amanda Long, Ron Mataya, Colin McCord, Meredith McMorrow, H
nager, Raul Mendoza–Sassi, William Menson, Pierre–Marie Metangmo, Gita Mirchandani, Mary Morgan
Neat, Oluwatosin Ogundalu, Pat Paredes, Vikash Parekh, Carlo Passeri, Zohra Patel, Erika Perez, Henr
Laura Podewils, Jon Poehlman, Ramaswamy Premkumar, Braveen Ragunanthan, Bahie Mary Rassekh
ca, Jeeva Rima, Jon Rohde, Evan Russell, Emma Sacks, Kwame Sakyi, Juan Sanchez, Nirali Shah, Manj
kar, Mona Sharan, Donna Sillan, Stephen Stake, Laura Steinhardt, Parminder Suchdev, Mariame Sylla
Tamarro, Henry Taylor, Muyiwa Tegbe, Angeline Ti, Charles Teller, Yetsa Tuakli, Jess Wilhelm, Olga W
Jean Yuan. Most of them helped as unpaid volunteers. Further information about them is contained in
of the online supplementary document. Binita Adhikari, Omar Balsara, David Exe, Pam Flynn, Jen
Mary Carol Jennings, Mirlene Perry, Elizabeth Randolph, Meike Schleiff provided assistance with assem
database and inputting it into an electronic format. Claire Twose provided expert technical assistance
puterized literature search. We thank them all. The organizations that provided financial support had
the execution of the review.
Funding: The following organizations provided funds that were used to conduct the work described i
ticle: The World Health Organization, UNICEF, the World Bank, the United States Agency for Internatio
velopment, and the Gates Foundation. The organizations that provided financial support had no role i
ecution of the review.
Authorship declaration: HP wrote the first draft. HP, PF, BR, and SG guided this project from the be
end and participated in all decisions related to the overall review. JS performed the analysis of the qu
included in our report. All of the authors participated in the revision of earlier drafts and approved the
Conflict of interest: All authors have completed the Unified Competing Interest Form at www.icmje
closure.pdf (available upon request from the corresponding author), and declare no conflict of interes
1Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. How many child deaths can we prevent this year?
2003;362:65-71. Medline:12853204 doi:10.1016/S0140-6736(03)13811-1
2Hill Z, Kirkwood B, Edmond K. Family and community practices that promote child survival, growth and d
a review of the evidence. Geneva: World Health Organization; 2004.
3Lassi ZS, Kumar R, Bhutta ZA. Community-based care to improve maternal, newborn, and child health. 2
ease Control Priorities: Reproductive, Maternal, Newborn, and Child Health, Third Edition. Washington, DC
Bank. Available:https://openknowledge.worldbank.org/bitstream/handle/10986/23833/9781464803482.
pdf?sequence=3&isAllowed=y26 February 2017. Accessed: 27 February 2017.
4 Bhutta ZA, Black RE. Global maternal, newborn, and child health–so near and yet so far. N Engl J Med. 2
35. Medline:24304052 doi:10.1056/NEJMra1111853
REFERENCES
Perry et al.
June 2017 • Vol. 7 No. 1 • 010901 12 www.jogh.org • doi: 10.7189/jogh.07.010901

VIEWPOINTSPAPERS
5 Black RE, Levin C, Walker N, Chou D, Liu L, Temmerman M, et al. Reproductive, maternal, newborn, a
key messages from Disease Control Priorities 3rd Edition. Lancet. 2016;388:2811-24.
6 Victora CG, Requejo JH, Barros AJ, Berman P, Bhutta Z, Boerma T, et al. Countdown to 2015: a decade
ress for maternal, newborn, and child survival. Lancet. 2016;387:2049-59. Medline:26477328 doi:10.10
6736(15)00519-X
7Bhutta ZA, Darmstadt GL, Hasan BS, Haws RA. Community-based interventions for improving perinatal
health outcomes in developing countries: a review of the evidence. Pediatrics. 2005;115(2 Suppl):519-
line:15866863 doi:10.1542/peds.2004-1441
8Freeman P, Perry HB, Gupta SK, Rassekh B. Accelerating progress in achieving the millennium develop
children through community-based approaches. Glob Public Health. Glob Public Health. 2012;7:400-19.
line:19890758 doi:10.1080/17441690903330305
9 Bhutta ZA, Lassi ZS, Pariyo G, Huicho L. Global experience of Community Health Workers for delivery
Millennium Development Goals: a systematic review, country case studies, and recommendation for in
tional health systems. Geneva: World Health Organization and the Global Health Workforce Alliance; 20
www.who.int/workforcealliance/knowledge/publications/alliance/Global_CHW_web.pdf. Accessed: 26 Fe
10 Gogia S, Sachdev HS. Home visits by community health workers to prevent neonatal deaths in develo
systematic review. Bull World Health Organ. 2010;88:658-66B. Medline:20865070 doi:10.2471/BLT.09.
11Kidney E, Winter HR, Khan KS, Gulmezoglu AM, Meads CA, Deeks JJ, et al. Systematic review of effect o
level interventions to reduce maternal mortality. BMC Pregnancy Childbirth. 2009;9:2. Medline:1
doi:10.1186/1471-2393-9-2
12 Lassi ZS, Haider BA, Bhutta ZA. Community-based intervention packages for reducing maternal and n
ity and mortality and improving neonatal outcomes. Cochrane Database Syst Rev. 2010;11:CD007754.
13Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, van Wyk BE, et al. Lay health
primary and community health care for maternal and child health and the management of infectious d
Database Syst Rev. 2010;3:CD004015. Medline:20238326
14 Salam RA, Haroon S, Ahmed HH, Das JK, Bhutta ZA. Impact of community-based interventions on HIV
titudes, and transmission. Infect Dis Poverty. 2014;3:26. Medline:25126420 doi:10.1186/2049-9957-3-2
15 Sazawal S, Black RE. Effect of pneumonia case management on mortality in neonates, infants, and pr
meta-analysis of community-based trials. Lancet Infect Dis. 2003;3:547-56. Medline:12954560 doi:10.1
3099(03)00737-0
16Schiffman J, Darmstadt GL, Agarwal S, Baqui AH. Community-based intervention packages for improvin
health in developing countries: a review of the evidence. Semin Perinatol. 2010;34:462-76. Medline:21094420
doi:10.1053/j.semperi.2010.09.008
17Miller S, Abalos E, Chamillard M, Ciapponi A, Colaci D, Comande D, et al. Beyond too little, too late and
soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet. 2016;388:2176
line:27642019 doi:10.1016/S0140-6736(16)31472-6
18 Chan M. Return to Alma-Ata. Lancet. 2008;372:865-6. Medline:18790292 doi:10.1016/S0140-6736(08
19 Arole M, Kasaje D, Taylor C. The Christian Medical Commission’s Role in the Worldwide Primary Health
ment. In: Taylor C, Desai A, Knutsson K, O’Dea-Knutsson P, Taylor-Ide D, editors. Partnerships for Socia
A Casebook. Franklin, WV, USA: Future Generations; 1995.
20 Litsios S. The long and difficult road to Alma-Ata: a personal reflection. Int J Health Serv. 2002;32:709
line:12456122 doi:10.2190/RP8C-L5UB-4RAF-NRH2
21 Litsios S. The Christian Medical Commission and the development of the World Health Organization’s
care approach. Am J Public Health. 2004;94:1884-93. Medline:15514223 doi:10.2105/AJPH.94.11.1884
22 Newell KW, editor. Health by the People. Geneva, Switzerland: World Health Organization; 1975.
23 WHO. UNICEF. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, U
tember 1978 Geneva, Switzerland: World Health Organization; 1978. Available: http://www.who.int/pub
maata_declaration_en.pdf?ua=1. Accessed: 27 February 2017.
24 WHO. UNICEF (editors). International Conference on Primary Health Care, Alma Ata. 1978; USSR: Wor
ganization, Geneva.
25 Ahmad OB, Lopez AD, Inoue M. The decline in child mortality: a reappraisal. Bull World Health Organ.
91. Medline:11100613
26 You D, Hug L, Ejdemyr S, Idele P, Hogan D, Mathers C, et al. Global, regional, and national levels and
mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by th
cy Group for Child Mortality Estimation. Lancet. 2015;386:2275-86. Medline:26361942 doi:10.101
6736(15)00120-8
27 UNICEF. The State of the World's Children 2015: Reimagine the Future. Innovation for Every Child. Ne
CEF; 2014. Available: http://sowc2015.unicef.org/. Accessed: 27 February 2017.
28 WHO, World Bank, UNICEF, UNFPA. Trends in Maternal Mortality: 1990 to 2015. 2015. World Health Or
Available: http://apps.who.int/iris/bitstream/10665/194254/1/9789241565141_eng.pdf?ua=1. Accessed
2016.
29 UNICEF. Tracking Progress in Maternal, Newborn and Child Survival. The 2008 Report New York: Gene
able: http://www.who.int/pmnch/Countdownto2015FINALREPORT-apr7.pdf. Accessed: 27 February 2017
REFERENCES
CBPHC, rationale, methods and database descrip
www.jogh.org • doi: 10.7189/jogh.07.010901 13 June 2017 • Vol. 7 No. 1 • 010901

VIEWPOINTSPAPERS
30Evaluation: the top priority for global health. Lancet. 2010;375:526. Medline:20079530 doi:10.101
6736(10)60056-6
31Rohde JE, Wyon J, editors. Community-Based Health Care: Lessons from Bangladesh to Boston. Boston, M
ment Sciences for Health (in collaboration with the Harvard School of Public Health); 2002.
32Black R. Taylor. C, Expert Panel. Comprehensive review of the evidence regarding the effectiveness of co
primary health care in improving maternal, neonatal and child health: 8. conclusions and recommendatio
pert Panel. J Glob Health. 2017;7:010908.
33Kark SL, Cassel J. The Pholela Health Centre; a progress report. S Afr Med J. 1952;26:101-4. Medline:1491
34Newell KW, Duenas Lehmann A, LeBlanc DR, Garces Osorio N. The use of toxoid for the prevention of tet
torum. Final report of a double-blind controlled field trial. Bull World Health Organ. 1966;35:863-71. Med
35 Jennings M, Pradhan S, Schleiff M, Sacks E, Freeman P, Gupta S, et al. Comprehensive review of the evi
the effectiveness of community-based primary health care in improving maternal, neonatal and child hea
health findings. J Glob Health. 2017;7:010902.
36 Sacks E, Freeman P, Sakyi K, Jennings M, Rassekh B, Gupta S, et al. Comprehensive review of the evide
effectiveness of community-based primary health care in improving maternal, neonatal and child health:
health findings. J Glob Health. 2017;7:010903.
37 Freeman P, Schleiff M, Sacks E, Rassekh B, Gupta S, Perry H. Comprehensive review of the evidence re
fectiveness of community-based primary health care in improving maternal, neonatal and child health: 4
findings. J Glob Health. 2017;7:010904.
38Perry H, Rassekh B, Gupta S, Freeman P. Comprehensive review of the evidence regarding the effectiven
nity-based primary health care in improving maternal, neonatal and child health: 6. strategies used by e
J Glob Health. 2017;7:010906.
39 Perry H, Rassekh B, Gupta S, Freeman P. Comprehensive review of the evidence regarding the effective
nity-based primary health care in improving maternal, neonatal and child health: 7. Programs with evide
term impact on mortality in children younger than five years of age. J Glob Health. 2017;7:010907.
40 Schleiff M, Kumapley R, Freeman P, Gupta S, Rassekh B, Perry H. Comprehensive review of the evidenc
effectiveness of community-based primary health care in improving maternal, neonatal and child health:
fects. J Glob Health. 2017;7:010905.
REFERENCES
Perry et al.
June 2017 • Vol. 7 No. 1 • 010901 14 www.jogh.org • doi: 10.7189/jogh.07.010901