Comprehensive Health Insurance and access to maternal healthcare services among Peruvian women: a cross-sectional study using the 2021 national demographic survey.

BACKGROUND: The government-subsidized health insurance scheme Seguro Integral de Salud ("SIS") was introduced in Peru initially to provide coverage to uninsured and poor pregnant women and children under five years old and was later extended to cover all uninsured members of the population following the Peruvian Plan Esencial de Aseguramiento Universal - "PEAS" (Essential UHC Package). Our study aimed to analyze the extent to which the introduction of SIS has increased equity in access and quality by comparing the utilization of maternal healthcare services among women with different insurance coverages. METHODS: Relying on the 2021 round of the nationally-representative survey "ENDES" (Encuesta Nacional Demográfica y de Salud Familiar), we analyzed data for 19,181 women aged 15-49 with a history of pregnancy in the five years preceding the survey date. We used a series of logistic regressions to explore the association between health insurance coverage (defined as No Insurance, SIS, or Standard Insurance) and a series of outcome variables measuring access to and quality of all services along the available maternal healthcare continuum. RESULTS: Only 46.5% of women across all insurance schemes reported having accessed effective ANC prevention. Findings from the adjusted logistic regression confirmed that insured women were more likely to have accessed ANC services compared with uninsured women. Our findings indicate that women in the "SIS" group were more likely to have accessed six ANC visits (aOR = 1.40; 95% CI 1.14-1.73) as well as effective ANC prevention (aOR = 1.32; 95% CI 1.17-1.48), ANC education (aOR = 1.59; 95% CI 1.41-1.80) and ANC screening (aOR = 1.46; 95% CI 1.27-1.69) during pregnancy, compared with women in the "Standard Insurance" group [aOR = 1.35 (95% CI 1.13-1.62), 1.22 (95% CI 1.04-1.42), 1.34 (95% CI 1.18-1.51) and 1.31(95% CI 1.15-1.49)] respectively. In addition, women in the "Standard Insurance" group were more likely to have received skilled attendance at birth (aOR = 2.17, 95% CI 1.33-3.55) compared with the women in the "SIS" insurance group (aOR = 2.12; 95% CI 1.41-3.17). CONCLUSIONS: Our findings indicate the persistence of inequities in access to maternal healthcare services that manifest themselves not only in the reduced utilization among the uninsured, but also in the lower quality of service coverage that uninsured women received compared with women insured under "Standard Insurance" or "SIS". Further policy reforms are needed both to expand insurance coverage and to ensure that all women receive the same access to care irrespective of their specific insurance coverage.

The impact of the COVID-19 pandemic on trends in stillbirths, under-5 and maternal mortality in Brazil: Excess deaths and regional inequalities.

Background: Despite the proliferation of studies on the impact of the coronavirus disease 2019 (COVID-19) pandemic, there is less evidence on the indirect death toll compared to the health system and service provision disruptions. We assessed the impact of the COVID-19 pandemic on national and regional trends and differences in stillbirths, under-5 and maternal deaths in Brazil. Methods: We used the nationwide routine health information system data from January 2017 to December 2021, to which we applied descriptive and advanced mixed effects ordinary least squared regression models to measure the percent change in mortality levels during the COVID-19 pandemic (March 2020 to December 2021). We carried out counterfactual analyses comparing the observed and expected mortality levels for each type of mortality at national and regional levels. Results: Stillbirths increased 4.8% (3.1% in 2020 and 6.2% in 2021) and most noticeably maternal deaths increased 71.6% (35.3% in 2020 and 103.3% in 2021) over the COVID-19 period. An opposite pattern was observed in under-5 mortality, which dropped -10.2% (-12.5% in 2020 and -8.1% in 2021). We identified regional disparities, with a higher percent increase in stillbirths observed in the Central-West region and in maternal deaths in the South region. Discussion: Based on pre-pandemic trends and expected number of deaths in the absence of the COVID-19, we observed increases in stillbirths and maternal deaths and reductions in under-5 deaths during the pandemic. The months with the highest number of deaths (stillbirths and maternal deaths) coincided with the months with the highest mortality from COVID-19. The increase in deaths may also have resulted from indirect effects of the pandemic, such as unavailability of health services or even reluctance to go to the hospital when necessary due to fear of contagion. Conclusions: In Brazil, the COVID-19 outbreak and subsequent restrictions had a detrimental impact on stillbirths and maternal deaths. Even before the pandemic, mortality trends highlighted pre-existing regional inequalities in the country's health care system. Although there were some variations, increases were observed in all regions, indicating potential weaknesses in the health system and inadequate management during the pandemic, particularly concerning pregnant and postpartum women.

COVID-19 and drivers of excess death rate in Peru: A longitudinal ecological study.

Background: Peru has experienced unprecedented mortality and economic toll due to the COVID-19 (Coronavirus disease 2019) pandemic in 2020. We aimed to assess the association between socioeconomic factors and excess death rate, and to explore the relative contribution of these factors to the differences in excess death rate during January-December 2020. Methods: Different national secondary data sources were used to describe excess death rates and different determinants, from distal to proximal. A confounding-adjusted multilevel mixed-effects linear regression was used to assess the association between these variables and excess death rates. Their relative contributions to the differences in excess death rate between the periods with the highest and lowest excess death rates were analyzed through regression-based Oaxaca-Blinder decomposition methods. Findings: The excess death rate showed an increasing trend in all regions, with different slopes. The confounding-adjusted multilevel analysis showed that higher healthcare access was associated with lower excess death rates (difference (95%CI) -0.004 (-0.005, -0.002)), whereas COVID-19 incidence was associated with higher excess death rates (difference (95%CI) 0.052 (0.042, 0.063)). The decomposition analysis showed COVID-19 incidence (41.9%), per capita income (19.4%) and unemployment rate (14.6%) as the main risk factors, while the main protective factors included per capita health expenditure (44.7%), healthcare access (33.2%) and health insurance (12.1%). Interpretation: Our study suggests that the excess death rate during the COVID-19 pandemic in Peru may have been influenced by other factors besides COVID-19 incidence, from distal to proximal drivers, including socioeconomic determinants, factors outside and within the health sector, and susceptibility factors. Further studies at individual level are needed to corroborate our findings.

Geographic inequalities in health intervention coverage - mapping the composite coverage index in Peru using geospatial modelling.

BACKGROUND: The composite coverage index (CCI) provides an integrated perspective towards universal health coverage in the context of reproductive, maternal, newborn and child health. Given the sample design of most household surveys does not provide coverage estimates below the first administrative level, approaches for achieving more granular estimates are needed. We used a model-based geostatistical approach to estimate the CCI at multiple resolutions in Peru. METHODS: We generated estimates for the eight indicators on which the CCI is based for the departments, provinces, and areas of 5 × 5 km of Peru using data from two national household surveys carried out in 2018 and 2019 plus geospatial covariates. Bayesian geostatistical models were fit using the INLA-SPDE approach. We assessed model fit using cross-validation at the survey cluster level and by comparing modelled and direct survey estimates at the department-level. RESULTS: CCI coverage in the provinces along the coast was consistently higher than in the remainder of the country. Jungle areas in the north and east presented the lowest coverage levels and the largest gaps between and within provinces. The greatest inequalities were found, unsurprisingly, in the largest provinces where populations are scattered in jungle territory and are difficult to reach. CONCLUSIONS: Our study highlighted provinces with high levels of inequality in CCI coverage indicating areas, mostly low-populated jungle areas, where more attention is needed. We also uncovered other areas, such as the border with Bolivia, where coverage is lower than the coastal provinces and should receive increased efforts. More generally, our results make the case for high-resolution estimates to unveil geographic inequities otherwise hidden by the usual levels of survey representativeness.

Indigenous communities' responses to the COVID-19 pandemic and consequences for maternal and neonatal health in remote Peruvian Amazon: a qualitative study based on routine programme supervision.

AIM: To explore indigenous communities' responses to the COVID-19 pandemic and its consequences for maternal and neonatal health (MNH) care in the Peruvian Amazon. METHODS: Mamás del Río is a community-based, MNH programme with comprehensive supervision covering monthly meetings with community health workers (CHW), community leaders and health facilities. With the onset of the lockdown, supervisors made telephone calls to discuss measures against COVID-19, governmental support, CHW activities in communities and provision of MNH care and COVID-19 preparedness at facilities. As part of the programme's ongoing mixed methods evaluation, we analysed written summaries of supervisor calls collected during the first 2 months of Peru's lockdown. RESULTS: Between March and May 2020, supervisors held two rounds of calls with CHWs and leaders of 68 communities and staff from 17 facilities. Most communities banned entry of foreigners, but about half tolerated residents travelling to regional towns for trade and social support. While social events were forbidden, strict home isolation was only practised in a third of communities as conflicting with daily routine. By the end of April, first clusters of suspected cases were reported in communities. COVID-19 test kits, training and medical face masks were not available in most rural facilities. Six out of seven facilities suspended routine antenatal and postnatal consultations while two-thirds of CHWs resumed home visits to pregnant women and newborns. CONCLUSIONS: Home isolation was hardly feasible in the rural Amazon context and community isolation was undermined by lack of external supplies and social support. With sustained community transmission, promotion of basic hygiene and mask use becomes essential. To avoid devastating effects on MNH, routine services at facilities need to be urgently re-established alongside COVID-19 preparedness plans. Community-based MNH programmes could offset detrimental indirect effects of the pandemic and provide an opportunity for local COVID-19 prevention and containment.

Global strategies and local implementation of health and health-related SDGs: lessons from consultation in countries across five regions.

Evidence on early achievements, challenges and opportunities would help low-income and middle-income countries (LMICs) accelerate implementation of health and health-related sustainable development goals (HHSDGs). A series of country-specific and multicountry consultative meetings were conducted during 2018-2019 that involved 15 countries across five regions to determine the status of implementation of HHSDGs. Almost 120 representatives from health and non-health sectors participated. The assessment relied on a multidomain analytical framework drawing on existing public health policy frameworks. During the first 5 years of the sustainable development goals (SDGs) era, participating LMICs from South and Central Asia, East Africa and Latin America demonstrated growing political commitment to HHSDGs, with augmentation of multisectoral institutional arrangements, strengthening of monitoring systems and engagement of development partners. On the other hand, there has been limited involvement of civic society representatives and academia, relatively few capacity development initiatives were in place, a well-crafted communication strategy was missing, and there is limited evidence of additional domestic financing for implementing HHSDGs. While the momentum towards universal health coverage is notable, explicit linkages with non-health SDGs and integrated multisectoral implementation strategies are lacking. The study offers messages to LMICs that would allow for a full decade of accelerated implementation of HHSDGs, and points to the need for more implementation research in each domain and for testing interventions that are likely to work before scale-up.

Drivers of stunting reduction in Peru: a country case study.

BACKGROUND: Peru reduced its under-5 child stunting prevalence notably from 31.3% in 2000 to 13.1% in 2016. OBJECTIVES: We aimed to study factors and key enablers of child stunting reduction in Peru from 2000-2016. METHODS: Demographic and Health Surveys were used to conduct descriptive analyses [height-for-age z scores (HAZ) means and distributions, equity analysis, predicted child growth curves through polynomial regressions] and advanced regression analyses. An ecological (at department level) multilevel regression analysis was conducted to identify the major predictors of stunting decline from 2000 to 2016, and Oaxaca-Blinder decomposition was conducted to identify the relative contribution of each factor to child HAZ change. A systematic literature review, policy and program analysis, and interviews with relevant stakeholders were conducted to understand key drivers of stunting decline in Peru. RESULTS: The distribution of HAZ scores showed a slight rightward shift from 2000 to 2007/2008, and a greater shift from 2007/2008 to 2016. Stunting reduction was higher in the lowest wealth quintile, in rural areas, and among children with the least educated mothers. Decomposing predicted changes showed that the most important factors were increased maternal BMI and maternal height, improved maternal and newborn health care, increased parental education, migration to urban areas, and reduced fertility. Key drivers included the advocacy role of civil society and political leadership around poverty and stunting reduction since the early 2000s. Key enablers included the economic growth and the consolidation of democracy since the early 2000s, and the acknowledgement that stunting reduction needs much more than food supplementation. CONCLUSIONS: Peru reduced child stunting owing to improved socioeconomic determinants, sustained implementation of out-of-health-sector and within-health-sector changes, and implementation of health interventions. These efforts were driven through a multisectoral approach, strong civil society advocacy, and keen political leadership. Peru's experience offers useful lessons on how to tackle the problem of stunting under differing scenarios, with the participation of multiple sectors.

Lenses and levels: the why, what and how of measuring health system drivers of women's, children's and adolescents' health with a governance focus.

Health systems are critical for health outcomes as they underpin intervention coverage and quality, promote users' rights and intervene on the social determinants of health. Governance is essential for health system endeavours as it mobilises and coordinates a multiplicity of actors and interests to realise common goals. The inherently social, political and contextualised nature of governance, and health systems more broadly, has implications for measurement, including how the health of women, children and adolescents health is viewed and assessed, and for whom. Three common lenses, each with their own views of power dynamics in policy and programme implementation, include a service delivery lens aimed at scaling effective interventions, a societal lens oriented to empowering people with rights to effect change and a systems lens concerned with creating enabling environments for adaptive learning. We illustrate the implications of each lens for the why, what and how of measuring health system drivers across micro, meso and macro health systems levels, through three examples (digital health, maternal and perinatal death surveillance and review, and multisectoral action for adolescent health). Appreciating these underpinnings of measuring health systems and governance drivers of the health of women, children and adolescents is essential for a holistic learning and action agenda that engages a wider range of stakeholders, which includes, but also goes beyond, indicator-based measurement. Without a broadening of approaches to measurement and the types of research partnerships involved, continued investments in the health of women, children and adolescents will fall short.

Understanding drivers of domestic public expenditure on reproductive, maternal, neonatal and child health in Peru at district level: an ecological study.

BACKGROUND: Peru has increased substantially its domestic public expenditure in maternal and child health. Peruvian departments are heterogeneous in contextual and geographic factors, underlining the importance of disaggregated expenditure analysis up to the district level. We aimed to assess possible district level factors influencing public expenditure on reproductive, maternal, neonatal and child health (RMNCH) in Peru. METHODS: We performed an ecological study in 24 departments, with specific RMNCH expenditure indicators as outcomes, and covariates of different hierarchical dimensions as predictors. To account for the influence of variables included in the different dimensions over time and across departments, we chose a stepwise multilevel mixed-effects regression model, with department-year as the unit of analysis. RESULTS: Public expenditure increased in all departments, particularly for maternal-neonatal and child health activities, with a different pace across departments. The multilevel analysis did not reveal consistently influential factors, except for previous year expenditure on reproductive and maternal-neonatal health. Our findings may be explained by a combination of inertial expenditure, a results-based budgeting approach to increase expenditure efficiency and effectiveness, and by a mixed-effects decentralization process. Sample size, interactions and collinearity cannot be ruled out completely. CONCLUSIONS: Public district-level RMNCH expenditure has increased remarkably in Peru. Evidence on underlying factors influencing such trends warrants further research, most likely through a combination of quantitative and qualitative approaches.

Enabling reproductive, maternal, neonatal and child health interventions: Time trends and driving factors of health expenditure in the successful story of Peru.

We compared expenditure trends for reproductive, maternal, neonatal and child health (RMNCH) with trends in RMNCH service coverage in Peru. We used National Health Accounts data to report on total health expenditure by source; the Countdown database for trends in external funding to RMNCH, and Ministry of Finance data for trends in domestic funding to RMNCH. We undertook over 170 interviews and group discussions to explore factors explaining expenditure trends. We describe trends in total health expenditure and RMNCH expenditure in constant 2012 US$ between 1995 and 2012. We estimated expenditure to coverage ratios. There was a substantial increase in domestic health expenditure over the period. However, domestic health expenditure as share of total government spending and GDP remained stable. Out-of-pocket health spending (OOPS) as a share of total health expenditure remained above 35%, and increased in real terms. Expenditure on reproductive health per woman of reproductive age varied from US$ 1.0 in 2002 to US$ 6.3 in 2012. Expenditure on maternal and neonatal health per pregnant woman increased from US$ 34 in 2000 to US$ 512 in 2012, and per capita expenditure on under-five children increased from US$ 5.6 in 2000 to US$ 148.6 in 2012. Increased expenditure on RMNCH reflects a greater political support for RMNCH, along with greater emphasis on social assistance, family planning, and health reforms targeting poor areas, and a recent emphasis on antipoverty and crosscutting equitable policies and programmes focused on nutrition and maternal and neonatal mortality. Increasing domestic RMNCH expenditure likely enabled Peru to achieve substantial health gains. Peru can provide useful lessons to other countries struggling to achieve sustained gains in RMNCH by relying on their own health financing.

Ethnic group inequalities in coverage with reproductive, maternal and child health interventions: cross-sectional analyses of national surveys in 16 Latin American and Caribbean countries.

BACKGROUND: Latin American and Caribbean populations include three main ethnic groups: indigenous people, people of African descent, and people of European descent. We investigated ethnic inequalities among these groups in population coverage with reproductive, maternal, newborn, and child health interventions. METHODS: We analysed 16 standardised, nationally representative surveys carried out from 2004 to 2015 in Latin America and the Caribbean that provided information on ethnicity or a proxy indicator (household language or skin colour) and on coverage of reproductive, maternal, newborn, and child health interventions. We selected four outcomes: coverage with modern contraception, antenatal care coverage (defined as four or more antenatal visits), and skilled attendants at birth for women aged 15-49 years; and coverage with three doses of diphtheria-pertussis-tetanus (DPT3) vaccine among children aged 12-23 months. We classified women and children as indigenous, of African descent, or other ancestry (reference group) on the basis of their self-reported ethnicity or language. Mediating variables included wealth quintiles (based on household asset indices), woman's education, and urban-rural residence. We calculated crude and adjusted coverage ratios using Poisson regression. FINDINGS: Ethnic gaps in coverage varied substantially from country to country. In most countries, coverage with modern contraception (median coverage ratio 0·82, IQR 0·66-0·92), antenatal care (0·86, 0·75-0·94), and skilled birth attendants (0·75, 0·68-0·92) was lower among indigenous women than in the reference group. Only three countries (Nicaragua, Panama, and Paraguay) showed significant gaps in DPT3 coverage between the indigenous and the reference groups. The differences were attenuated but persisted after adjustment for wealth, education, and residence. Women and children of African descent showed similar coverage to the reference group in most countries. INTERPRETATION: The lower coverage levels for indigenous women are pervasive, and cannot be explained solely by differences in wealth, education, or residence. Interventions delivered at community level-such as vaccines-show less inequality than those requiring access to services, such as birth attendance. Regular monitoring of ethnic inequalities is essential to evaluate existing initiatives aimed at the inclusion of minorities and to plan effective multisectoral policies and programmes. FUNDING: The Bill & Melinda Gates Foundation (through the Countdown to 2030 initiative) and the Wellcome Trust.

Measuring Socioeconomic Status and Environmental Factors in the SAYCARE Study in South America: Reliability of the Methods.

OBJECTIVE: This paper aimed to test the reliability of two questionnaires in studies involving children and adolescents (aged 3-18 years) in seven South American cities. One assesses socioeconomic status (SES) and the other measures environmental factors. METHODS: The SES questionnaire was composed of 14 questions, which included the presence of several consumer goods, domestic services, family income, parental education level, and current parental occupation status. The environmental questionnaire was composed of 15 questions to measure the social and infrastructure characteristics of the area of residence. Parents or guardians completed the questionnaires on behalf of their children. Adolescents answered the questions themselves for environmental factors, while those related to SES factors were answered by their parents or guardians. We analyzed the reliability of the questionnaires through kappa coefficient determination. Multilevel linear regression models were applied to calculate the correlation between the total household scores, the household income, and parents' education level. RESULTS: The environmental questionnaire showed good reproducibility in both age groups (k = 0.132-0.612 in children and k = 0.392-0.746 in adolescents). The SES questionnaire showed strong reliability in both age groups for all indicators (k = 0.52-1.00 in children and k = 0.296-0.964 in adolescents). CONCLUSIONS: Our multiple indicator questionnaires focused on environmental factors and SES in pediatric health surveys provided useful and easily applicable additional indicators to measure these important determinants of cardiovascular health.

Prioritizing research for integrated implementation of early childhood development and maternal, newborn, child and adolescent health and nutrition platforms.

BACKGROUND: Existing health and nutrition services present potential platforms for scaling up delivery of early childhood development (ECD) interventions within sensitive windows across the life course, especially in the first 1000 days from conception to age 2 years. However, there is insufficient knowledge on how to optimize implementation for such strategies in an integrated manner. In light of this knowledge gap, we aimed to systematically identify a set of integrated implementation research priorities for health, nutrition and early child development within the 2015 to 2030 timeframe of the Sustainable Development Goals (SDGs). METHODS: We applied the Child Health and Nutrition Research Initiative method, and consulted a diverse group of global health experts to develop and score 57 research questions against five criteria: answerability, effectiveness, deliverability, impact, and effect on equity. These questions were ranked using a research priority score, and the average expert agreement score was calculated for each question. FINDINGS: The research priority scores ranged from 61.01 to 93.52, with a median of 82.87. The average expert agreement scores ranged from 0.50 to 0.90, with a median of 0.75. The top-ranked research question were: i) "How can interventions and packages to reduce neonatal mortality be expanded to include ECD and stimulation interventions?"; ii) "How does the integration of ECD and MNCAH&N interventions affect human resource requirements and capacity development in resource-poor settings?"; and iii) "How can integrated interventions be tailored to vulnerable refugee and migrant populations to protect against poor ECD and MNCAH&N outcomes?". Most highly-ranked research priorities varied across the life course and highlighted key aspects of scaling up coverage of integrated interventions in resource-limited settings, including: workforce and capacity development, cost-effectiveness and strategies to reduce financial barriers, and quality assessment of programs. CONCLUSIONS: Investing in ECD is critical to achieving several of the SDGs, including SDG 2 on ending all forms of malnutrition, SDG 3 on ensuring health and well-being for all, and SDG 4 on ensuring inclusive and equitable quality education and promotion of life-long learning opportunities for all. The generated research agenda is expected to drive action and investment on priority approaches to integrating ECD interventions within existing health and nutrition services.

Factors behind the success story of under-five stunting in Peru: a district ecological multilevel analysis.

BACKGROUND: Stunting prevalence in children less than 5 years has remained stagnated in Peru from 1992 to 2007, with a rapid reduction thereafter. We aimed to assess the role of different predictors on stunting reduction over time and across departments, from 2000 to 2012. METHODS: We used various secondary data sources to describe time trends of stunting and of possible predictors that included distal to proximal determinants. We determined a ranking of departments by annual change of stunting and of different predictors. To account for variation over time and across departments, we used an ecological hierarchical approach based on a multilevel mixed-effects regression model, considering stunting as the outcome. Our unit of analysis was one department-year. RESULTS: Stunting followed a decreasing trend in all departments, with differing slopes. The reduction pace was higher from 2007-2008 onwards. The departments with the highest annual stunting reduction were Cusco (-2.31%), Amazonas (-1.57%), Puno (-1.54%), Huanuco (-1.52%), and Ancash (-1.44). Those with the lowest reduction were Ica (-0.67%), Ucayali (-0.64%), Tumbes (-0.45%), Lima (-0.37%), and Tacna (-0.31%). Amazon and Andean departments, with the highest baseline poverty rates and concentrating the highest rural populations, showed the highest stunting reduction. In the multilevel analysis, when accounting for confounding, social determinants seemed to be the most important factors influencing annual stunting reduction, with significant variation between departments. CONCLUSIONS: Stunting reduction may be explained by the adoption of anti-poverty policies and sustained implementation of equitable crosscutting interventions, with focus on poorest areas. Inclusion of quality indicators for reproductive, maternal, neonatal and child health interventions may enable further analyses to show the influence of these factors. After a long stagnation period, Peru reduced dramatically its national and departmental stunting prevalence, thanks to a combination of social determinants and crosscutting factors. This experience offers useful lessons to other countries trying to improve their children's nutrition.

Remaining missed opportunities of child survival in Peru: modelling mortality impact of universal and equitable coverage of proven interventions.

BACKGROUND: Peru has made great improvements in reducing stunting and child mortality in the past decade, and has reached the Millennium Development Goals 1 and 4. The remaining challenges or missed opportunities for child survival needs to be identified and quantified, in order to guide the next steps to further improve child survival in Peru. METHODS: We used the Lives Saved Tool (LiST) to project the mortality impact of proven interventions reaching every women and child in need, and the mortality impact of eliminating inequalities in coverage distribution between wealth quintiles and urban-rural residence. RESULTS: Our analyses quantified the remaining missed opportunities in Peru, where prioritizing scale-up of facility-based case management for all small and sick babies will be most effective in mortality reduction, compared to other evidenced-based interventions that prevent maternal and child deaths. Eliminating coverage disparities between the poorest quintiles and the richest will reduce under-five and neonatal mortality by 22.0 and 40.6 %, while eliminating coverage disparities between those living in rural and urban areas will reduce under-five and neonatal mortality by 29.3 and 45.2 %. This projected neonatal mortality reduction achieved by eliminating coverage disparities is almost comparable to that already achieved by Peru over the past decade. CONCLUSIONS: Although Peru has made great strides in improving child survival, further improvement in child health, especially in newborn health can be achieved if there is universal and equitable coverage of proven, quality health facility-based interventions. The magnitude of reduction in mortality will be similar to what has been achieved in the past decade. Strengthening health system to identify, understand, and direct resources to the poor and rural areas will ensure that Peru achieve the Sustainable Development Goals by 2030.

Countdown to 2015 country case studies: systematic tools to address the "black box" of health systems and policy assessment.

BACKGROUND: Evaluating health systems and policy (HSP) change and implementation is critical in understanding reproductive, maternal, newborn and child health (RMNCH) progress within and across countries. Whilst data for health outcomes, coverage and equity have advanced in the last decade, comparable analyses of HSP changes are lacking. We present a set of novel tools developed by Countdown to 2015 (Countdown) to systematically analyse and describe HSP change for RMNCH indicators, enabling multi-country comparisons. METHODS: International experts worked with eight country teams to develop HSP tools via mixed methods. These tools assess RMNCH change over time (e.g. 1990-2015) and include: (i) Policy and Programme Timeline Tool (depicting change according to level of policy); (ii) Health Policy Tracer Indicators Dashboard (showing 11 selected RMNCH policies over time); (iii) Health Systems Tracer Indicators Dashboard (showing four selected systems indicators over time); and (iv) Programme implementation assessment. To illustrate these tools, we present results from Tanzania and Peru, two of eight Countdown case studies. RESULTS: The Policy and Programme Timeline tool shows that Tanzania's RMNCH environment is complex, with increased funding and programmes for child survival, particularly primary-care implementation. Maternal health was prioritised since mid-1990s, yet with variable programme implementation, mainly targeting facilities. Newborn health only received attention since 2005, yet is rapidly scaling-up interventions at facility- and community-levels. Reproductive health lost momentum, with re-investment since 2010. Contrastingly, Peru moved from standalone to integrated RMNCH programme implementation, combined with multi-sectoral, anti-poverty strategies. The HSP Tracer Indicators Dashboards show that Peru has adopted nine of 11 policy tracer indicators and Tanzania has adopted seven. Peru costed national RMNCH plans pre-2000, whereas Tanzania developed a national RMNCH plan in 2006 but only costed the reproductive health component. Both countries included all lifesaving RMNCH commodities on their essential medicines lists. Peru has twice the health worker density of Tanzania (15.4 vs. 7.1/10,000 population, respectively), although both are below the 22.8 WHO minimum threshold. CONCLUSIONS: These are the first HSP tools using mixed methods to systematically analyse and describe RMNCH changes within and across countries, important in informing accelerated progress for ending preventable maternal, newborn and child mortality in the post-2015 era.

Countdown to 2015 country case studies: what can analysis of national health financing contribute to understanding MDG 4 and 5 progress?

BACKGROUND: Countdown to 2015 (Countdown) supported countries to produce case studies that examine how and why progress was made toward the Millennium Development Goals (MDGs) 4 and 5. Analysing how health-financing data explains improvements in RMNCH outcomes was one of the components to the case studies. METHODS: This paper presents a descriptive analysis on health financing from six Countdown case studies (Afghanistan, Ethiopia, Malawi, Pakistan, Peru, and Tanzania), supplemented by additional data from global databases and country reports on macroeconomic, health financing, demographic, and RMNCH outcome data as needed. It also examines the effect of other contextual factors presented in the case studies to help interpret health-financing data. RESULTS: Dramatic increases in health funding occurred since 2000, where the MDG agenda encouraged countries and donors to invest more resources on health. Most low-income countries relied on external support to increase health spending, with an average 20-64 % of total health spending from 2000 onwards. Middle-income countries relied more on government and household spending. RMNCH funding also increased since 2000, with an average increase of 119 % (2005-2010) for RMNH expenditures (2005-2010) and 165 % for CH expenditures (2005-2011). Progress was made, especially achieving MDG 4, even with low per capita spending; ranging from US$16 to US$44 per child under 5 years among low-income countries. Improvements in distal factors were noted during the time frame of the analysis, including rapid economic growth in Ethiopia, Peru, and Tanzania and improvements in female literacy as documented in Malawi, which are also likely to have contributed to MDG progress and achievements. CONCLUSIONS: Increases in health and RMNCH funding accompanied improvements in outcomes, though low-income countries are still very reliant on external financing, and out-of-pocket comprising a growing share of funds in middle-income settings. Enhancements in tracking RMNCH expenditures across countries are still needed to better understand whether domestic and global health financing initiatives lead to improved outcomes as RMNCH continues to be a priority under the Sustainable Development Goals.