The Tika Vaani collaboration brings together research, technology, and implementation partners united by a common vision: to create and evaluate impactful innovations to accelerate health equity and improve the lives of those at the bottom of the pyramid. “Tika Vaani” means “vaccine voice” in Hindi – our area of focus is social and technological innovations to strengthen child immunization outcomes through empowering communities and health workers.

Reaching underserved populations requires more effective immunization systems, and these in turn require improved immunization data. We have developed an application to help frontline workers equipped with a mobile smartphone in their tasks, which will ultimately help to strengthen immunization planning and other services for beneficiaries. The approach will change immunization data processes in three key ways. (1) The new, easy-to-use mobile phone application will enable health workers to collect immunization data in real time at point-of-service using optical character recognition (OCR) methods (“optical scanning”). (2) The system will also enable direct communication with beneficiaries, offering information about immunisation services and appointment reminders. (3) It will make immunization data available in high quality, at the right time, and in the right place to support system decision making. An early-stage evaluation is underway.

We believe that the Tika Vaani approach, which embeds appropriate technology into effective community processes, can contribute to better immunization coverage, equity, and timeliness, and healthier futures for children.

For more information on our work, please see: tikavaani.org

Public health interventions are typically evaluated using an experimental study design involving randomisation (such as a randomised controlled trial (RCT) or a cluster randomised trial (CRT)). Fidelity assessment examines study processes to gauge whether an intervention was delivered as initially planned. Evaluation of implementation fidelity is required to establish whether the measured effects of a trial are due to the intervention itself and may be particularly important for CRTs of complex interventions conducted in low- and middle-income countries (LMICs). However, current trial reporting guidelines offer no guidance on IF assessment. We aim to strengthen learning from complex intervention trials by conducting research to improve methods and guidance for IF.

Myriam Cielo Pérez*, Nanor Minoyan*, Valéry Ridde, Marie-Pierre Sylvestre, Mira Johri. Comparison of registered and published intervention fidelity assessment in cluster randomised trials of public health interventions in low- and middle-income countries: systematic review. Trials 2018; 19: 410.

Myriam Cielo Pérez*, Nanor Minoyan*, Valéry Ridde, Marie-Pierre Sylvestre, Mira Johri. Comparison of registered and published intervention fidelity assessment in cluster randomised trials of public health interventions in low- and middle-income countries: systematic review protocol, Systematic Reviews 2016, 5(1):177.

The WHO Department of maternal, newborn, child and adolescent health (WHO/MCA) and UNICEF Child Health Redesign are developing guidance to accelerate the improvements in child health and development required to meet the 2030 sustainable development goals. The new guidance requires a holistic view of child health that recognizes new epidemiological and demographic realities, moves beyond a mortality focus, encompasses a life-course perspective, focusses on integration and synergies among interventions, and includes environmental and social determinants. I am contributing to a work stream lead by WHO/MCA on social, behavioural and community engagement interventions, which have a key role to play in realizing this vision.

With colleagues from McGill University and Gavi, the Vaccine Alliance, I lead a project to design equity indicators to track global immunisation progress relevant to Gavi’s Sustainable Development Goals strategy. Analytic work was led by our doctoral student, Dr Catherine Arsenault. Based partly on results from our analysis, in its strategy for 2016-2020, which included a central focus on immunization coverage and equity, Gavi lowered the wealth quintile benchmark to 10 percentage points, and added indicators related to geographic equity and maternal education.

Catherine Arsenault, Sam Harper, Arijit Nandi, José Mendoza Rodriguez, Peter Hansen, Mira Johri. An equity dashboard to monitor vaccination coverage for the Sustainable Development Goals, Policy and Practice: Bull World Health Organ 2017;95(2):128–134

Catherine Arsenault, Sam Harper, Arijit Nandi, José Mendoza Rodriguez, Peter Hansen, Mira Johri. Monitoring equity in vaccination coverage: A systematic analysis of Demographic and Health Surveys from 45 Gavi-supported countries Vaccine 2017 Feb 7;35(6):951-959.

Catherine Arsenault, Mira Johri, Arijit Nandi, José M Mendoza Rodríguez, Peter M Hansen, Sam Harper. Country-level predictors of vaccination coverage and inequalities in Gavi-supported countries, Vaccine 35(18), 2479-2488.

With colleagues from the London School of Hygiene and Tropical Medicine, Harvard University, and the University of Toronto, we developed policy models leveraging India’s Million Deaths Study data to evaluate the mortality impact of India’s 2010-2013 measles campaigns, and to assess the mortality benefit of an alternative (hypothetical) strategy including additional high-impact health interventions along with measles vaccine in the campaign platform. We found that, in India, a measles vaccination campaign including feasible, high-impact interventions could substantially increase lives saved and mitigate gender-related inequities in child mortality as compared to a campaign delivering measles vaccine alone.

Drs. Verguet and Jit lead development of the mathematical model of measles disease burden and vaccine impact, DynaMICE (Dynamic Measles Immunisation Calculation Engine), now used by Gavi, the Bill & Melinda Gates Foundation, and other global partners. I lead the workstream studying the use of measles campaigns as a delivery platform for high-impact maternal and child health interventions in India. As our study and others have illustrated, an integrated delivery strategy that leverages the immunisation platform to strengthen primary care is aligned with the SDG focus on equity, Universal Health Coverage and Primary Health Care. Gavi is considering mechanisms to support this approach going forward.

Verguet S, Jones EO, Johri M, Morris SK, Suraweera W, Gauvreau CL, Jha P and Jit M: Characterizing measles transmission in India: a dynamic modeling study using verbal autopsy data. BMC Med 2017, 15(1):151.

Johri M, Verguet S, Morris SK, Sharma JK, Ram U, Gauvreau C, Jones E, Jha P and Jit M: Adding interventions to mass measles vaccinations in India. Bull World Health Organ 2016, 94(10):718-727.

Verguet S, Johri M, Morris SK, Gauvreau CL, Jha P and Jit M: Controlling measles using supplemental immunization activities: a mathematical model to inform optimal policy. Vaccine 2015, 33(10):1291- 1296.

Johri M, Sharma JK, Jit M and Verguet S: Use of measles supplemental immunization activities (SIAs) as a delivery platform for other maternal and child health interventions: opportunities and challenges. Vaccine 2013, 31(9):1259-1263.

Verguet, S.; Jit, M.; Johri, M. The broader economic benefits of measles supplemental immunisation activities as a delivery platform for other childhood interventions in India. Report to the World Health Organization. July 2013.

I served as co-investigator in a team lead by colleagues at the University of Montreal and in Burkina Faso studying the impact of a health financing reform for Universal Health Coverage (2012-2014). We analyzed the likely mortality impact of abolishing user fees for pregnant women and children in Burkina Faso, a high-mortality African country with slow progress in maternal, neonatal, and child health. We took a novel route to investigating mortality impact, by coupling use of a validated mathematical model with rigorous statistical techniques (propensity score and interrupted time-series) for impact assessment. Lead by Drs Ridde and Haddad, all aspects of this work were done in collaboration with a consortium of local and international NGOs and government stakeholders.

In March 2015, the Minister of Health of Burkina Faso cited our study in a presentation to international stakeholders as part of the rationale to expand a new policy to eliminate user-fees for curative child health services. On September 5, 2015, Burkina Faso adopted a law exempting children 0 to age 5 from user fees, as part of a move towards Universal Health Coverage. In April 2016, the Burkina Faso announced the intention to implement the policies studied in our analysis (elimination of user fees for children less than 5 year of age, for all deliveries (including caesareans), and for antenatal care) in three regions.

Johri M, Ridde V, Heinmuller R and Haddad S: Estimation of maternal and child mortality one year after user-fee elimination: an impact evaluation and modelling study in Burkina Faso. Bull World Health Organ 2014, 92(10):706-715.

The QUARISMA trial investigated the value of a clinician-training program to tackle a problem of worldwide concern: the increasing trend in caesarean deliveries. Trial results were published in the New England Journal of Medicine. The authors found a statistically significant but clinically small reduction in caesarean sections, with no adverse effects on mothers and children. Based on these results, it was unclear whether the intervention should be offered at scale.

With colleagues from the London School of Hygiene and Tropical Medicine and the University of Toronto, I lead the economic evaluation of the QUARISMA trial. We conducted a trial-based cost-effectiveness analysis using individual patient data to inform scale-up decisions. Our analysis showed that the training program for clinicians studied in the QUARISMA trial resulted in very favourable results: better quality of care for mothers and infants, and major cost savings (in the range of $15.8 million annually for the Province of Quebec). Cost reductions are consistent with improved quality of care in intervention group hospitals.

Based partly on our economic evaluation results, through a collaboration between the government and the MORE^OB Program, the QUARISMA intervention has been scaled up to all of the 66 obstetrical hospitals in the Province of Quebec; it is now being scaled up in the rest of Canada. In 2018, the World Health Organization released a landmark Guideline on non-clinical interventions to reduce unnecessary caesarean sections. The QUARISMA trial was among a select number of high-quality studies included in the guidelines, and ours was the only economic evaluation that met criteria for inclusion. The study provided a fundamental piece of evidence that audit and feedback interventions directed towards health professionals can improve quality of care while also controlling costs. Through their inclusion in the WHO guidelines, we expect these findings to have widespread impact.

Chaillet N, Dumont A, Abrahamowicz M, Pasquier JC, Audibert F, Monnier P, Abenhaim HA, Dube E, Dugas M, Burne R and al: A cluster-randomized trial to reduce cesarean delivery rates in Quebec. N Engl J Med 2015, 372(18):1710-1721.

Johri M, Ng ESW, Bermudez-Tamayo C*, Hoch JS, Ducruet T and Chaillet N: A cluster-randomized trial to reduce caesarean delivery rates in Quebec: cost-effectiveness analysis. BMC Med 2017, 15(1):96.

Bermudez-Tamayo C*, Johri M, Chaillet N: Budget impact of a program for safely reducing caesarean sections in Canada. Midwifery 2018, 60:20-26

I worked with a team of clinicians from Guatemala to design, implement and evaluate a programme to prevent mother-to-child transmission (pMTCT) of HIV in Guatemala– one of the first two pMTCT programs in Guatemala, and the first in the delivery room. My role was to strengthen evidence-based intervention design, acquire funding, and lead research and evaluation. I also conducted an evidence synthesis on the topic of prevention of HIV pMTCT and was invited to participate in a Copenhagen Consensus priority-setting exercise on HIV/AIDS in Sub-Saharan Africa.

The project was an important clinical and policy success, resulting in an estimated 14-22 children born without HIV (1 positive case), 5000 participants receiving HIV counselling and prevention, 54 women identified as HIV+ and linked to treatment, and 650 women counselled for abuse and violence. The clinical intervention was taken over by the Ministry of Health with support from the Global Fund. Our project was selected for the 2010 CIHR Knowledge Translation Casebook.

Johri M, Morales RE, Boivin JF, Samayoa BE, Hoch JS, Grazioso CF, Barrios Matta IJ, Sommen C, Baide Diaz EL, Fong HR and al: Increased risk of miscarriage among women experiencing physical or sexual intimate partner violence during pregnancy in Guatemala City, Guatemala: cross-sectional study. BMC Pregnancy Childbirth 2011, 11(1):49.

Johri M and Ako-Arrey D*: The cost-effectiveness of preventing mother-to-child transmission of HIV in low- and middle-income countries: systematic review. Cost Eff Resour Alloc 2011, 9:3.

Johri M, Morales RE, Hoch JS, Samayoa BE, Sommen C, Grazioso CF, Boivin JF, Barrios IJ, Baide E and Arathoon E: A cross-sectional study of risk factors for HIV among pregnant women in Guatemala City, Guatemala: Lessons for prevention. Int J STD AIDS 2010, 21:789-796.

Johri M. Alternative perspective: prevention of non-sexual transmission. In : Rethink HIV – Smarter Ways to Invest in Ending HIV in Sub-Saharan Africa Edited by Bjørn Lomborg. Cambridge University Press, 2012. Paperback  (ISBN-13: 9781107679320)