Countdown to 2015 country case studies: what have we learned about processes and progress towards MDGs 4 and 5?

Abstract

Background: Countdown to 2015 was a multi-institution consortium tracking progress towards Millennium Development Goals (MDGs) 4 and 5. Case studies to explore factors contributing to progress (or lack of progress) in reproductive, maternal, newborn and child health (RMNCH) were undertaken in: Afghanistan, Bangladesh, China, Ethiopia, Kenya, Malawi, Niger, Pakistan, Peru, and Tanzania. This paper aims to identify cross-cutting themes on how and why these countries achieved or did not achieve MDG progress.

Methods: Applying a standard evaluation framework, analyses of impact, coverage and equity were undertaken, including a mixed methods analysis of how these were influenced by national context and coverage determinants (including health systems, policies and financing).

Results: The majority (7/10) of case study countries met MDG-4 with over two-thirds reduction in child mortality, but none met MDG-5a for 75 % reduction in maternal mortality, although six countries achieved >75 % of this target. None achieved MDG-5b regarding reproductive health. Rates of reduction in neonatal mortality were half or less that for post-neonatal child mortality. Coverage increased most for interventions administered at lower levels of the health system (e.g., immunisation, insecticide treated nets), and these experienced substantial political and financial support. These interventions were associated with ~30-40 % of child lives saved in 2012 compared to 2000, in Ethiopia, Malawi, Peru and Tanzania. Intrapartum care for mothers and newborns -- which require higher-level health workers, more infrastructure, and increased community engagement -- showed variable increases in coverage, and persistent equity gaps. Countries have explored different approaches to address these problems, including shifting interventions to the community setting and tasks to lower-level health workers.

Conclusions: These Countdown case studies underline the importance of consistent national investment and global attention for achieving improvements in RMNCH. Interventions with major global investments achieved higher levels of coverage, reduced equity gaps and improvements in associated health outcomes. Given many competing priorities for the Sustainable Development Goals era, it is essential to maintain attention to the unfinished RMNCH agenda, particularly health systems improvements for maternal and neonatal outcomes where progress has been slower, and to invest in data collection for monitoring progress and for rigorous analyses of how progress is achieved in different contexts.

Keywords: Accountability; Child health; Coverage; Equity; Health finance; Health systems; Maternal health; Millennium Development Goals; Neonatal health; Reproductive health.

Fig. 1

Evaluation framework for Countdown to 2015 country case studies. Source: Afnan-Holmes et al. [11]

Fig. 2

Overview of the case study country selection, geography and focus along the continuum of care accounting to R (reproductive), M (maternal), N (newborn) and C (child) health

Fig. 3

Countdown to 2015 country case study progress to achieving MDGs 4 and 5 by income level. Data sources: MDG reports 2015, income level from the World Bank 2015. *i.e., % achievement of 66 % reduction for MDG 4 and 75 % reduction for MDG 5a

Fig. 4

Annual rate of reduction in impact indicators, in each Countdown to 2015 case study country, for the full MDG period (1990–2015), as well as for each decade (1990–2000 and 2000–2015). a Change in Neonatal & Under-5 Indicators. b Change in Total Fertility Rate. c Change in Maternal Mortality Ratio. Data sources: Analysis from UN Interagency Group for Child Mortality Estimation (IGME) in 2015; United Nations Population Division. World Population Prospects (WPP): The 2015 Revision. Total Fertility (TFR); WHO. 2015. Levels and Trends for Maternal Mortality: 1990 to 2015. Geneva: World Health Organization

Fig. 5

Most recent median national coverage (%) of selected Commission on Information and Accountability (CoIA) indicators in 75 Countdown to 2015 countries, with national coverage for case study countries. Grey bars indicate the median level of coverage per CoIA indicator across all 75 Countdown countries; dots represent the national level of coverage for each CoIA indicator per case study country

Fig. 6

Change in coverage of select Commission on Information and Accountability (CoIA) indicators in Countdown to 2015 case study countries, over time. This figure includes only those case study countries with available data. Antenatal care and skilled birth attendance are reported among births during the 3 years preceding the survey

Fig. 7

Coverage of select Commission on Information and Accountability (CoIA) indicators for Countdown to 2015 case study countries, in the poorest and richest wealth quintiles, over time (%). Figure 7 includes only those case study countries with available data. Antenatal care and skilled birth attendance are reported among births during the 3 years preceding the survey

Fig. 8

Estimated lives saved in Countdown to 2015 case study countries according to Lives Saved Tool (LIST) analyses which are associated with coverage of key interventions. a Children aged 1–59 months. b Newborns <1 month. c Children aged 0–59 months. All countries examine the year 2012 versus 2000 – except Ethiopia (*) which compares the year 2011 to 2000; and Pakistan (**) which compares 2012 to 2006. Negative numbers indicate a decrease in the coverage of an intervention over the period. LiST results from Malawi include averted deaths among children aged 0–59 months (#). Pregnancy and care includes obstetrics, essential newborn care, care of sick newborns and KMC. Nutrition includes breastfeeding, vitamin A supplementation, and measures to reduce wasting & stunting. Prevention and treatment of infections also includes pneumonia, malaria and diarrhoeal treatment, ITNs, vaccines and PMTCT. NB/ Deaths averted are only relating to those that can be explained by change in coverage of intervention