Benchmarking health system performance across districts in Zambia: a systematic analysis of levels and trends in key maternal and child health interventions from 1990 to 2010

Abstract

Background: Achieving universal health coverage and reducing health inequalities are primary goals for an increasing number of health systems worldwide. Timely and accurate measurements of levels and trends in key health indicators at local levels are crucial to assess progress and identify drivers of success and areas that may be lagging behind.

Methods: We generated estimates of 17 key maternal and child health indicators for Zambia's 72 districts from 1990 to 2010 using surveys, censuses, and administrative data. We used a three-step statistical model involving spatial-temporal smoothing and Gaussian process regression. We generated estimates at the national level for each indicator by calculating the population-weighted mean of the district values and calculated composite coverage as the average of 10 priority interventions.

Results: National estimates masked substantial variation across districts in the levels and trends of all indicators. Overall, composite coverage increased from 46% in 1990 to 73% in 2010, and most of this gain was attributable to the scale-up of malaria control interventions, pentavalent immunization, and exclusive breastfeeding. The scale-up of these interventions was relatively equitable across districts. In contrast, progress in routine services, including polio immunization, antenatal care, and skilled birth attendance, stagnated or declined and exhibited large disparities across districts. The absolute difference in composite coverage between the highest-performing and lowest-performing districts declined from 37 to 26 percentage points between 1990 and 2010, although considerable variation in composite coverage across districts persisted.

Conclusions: Zambia has made marked progress in delivering maternal and child health interventions between 1990 and 2010; nevertheless, substantial variations across districts and interventions remained. Subnational benchmarking is important to identify these disparities, allowing policymakers to prioritize areas of greatest need. Analyses such as this one should be conducted regularly and feed directly into policy decisions in order to increase accountability at the local, regional, and national levels.

Figure 1

Distribution of intervention coverage in 2010 (A) and absolute change in coverage from 1990 to 2010 among districts (B). IRS displayed only for targeted districts in 2010.

Figure 2

Coverage of insecticide-treated net ownership (A) and exclusive breastfeeding (B) by district in 2000, 2005, and 2010.

Figure 3

Absolute change in coverage between 1990 and 2010 compared with estimated coverage in 1990 for (A) antenatal care, 4 visits, (B) skilled birth attendance, and (C) polio immunization, by district. Each dot represents a district.

Figure 4

National composite coverage by intervention composition, 1990 to 2010.

Figure 5

Composite coverage by district and intervention cluster, 2010. Other MCH: ANC4, SBA, EBF, and proportion of children not underweight. Vaccines: BCG, measles, polio, and pentavalent. Malaria control: ITN ownership or IRS and IPTp2.