Assessing the Contribution of Malaria Vector Control and Other Maternal and Child Health Interventions in Reducing All-Cause Under-Five Mortality in Zambia, 1990-2010.

Under-five mortality in Zambia has declined since 1990, with reductions accelerating after 2000. Zambia's scale-up of malaria control is viewed as the driver of these gains, but past studies have not fully accounted for other potential factors. This study sought to systematically evaluate the impact of malaria vector control on under-five mortality. Using a mixed-effects regression model, we quantified the relationship between malaria vector control, other priority health interventions, and socioeconomic indicators and district-level under-five mortality trends from 1990 to 2010. We then conducted counterfactual analyses to estimate under-five mortality in the absence of scaling up malaria vector control. Throughout Zambia, increased malaria vector control coverage coincided with scaling up three other interventions: the pentavalent vaccine, exclusive breast-feeding, and prevention of mother-to-child transmission of HIV services. This simultaneous scale-up made statistically isolating intervention-specific impact infeasible. Instead, in combination, these interventions jointly accelerated declines in under-five mortality by 11% between 2000 and 2010. Zambia's scale-up of multiple interventions is notable, yet our findings highlight challenges in quantifying program-specific impact without better health data and information systems. As countries aim to further improve health outcomes, there is even greater need-and opportunity-to strengthen routine data systems and to develop more rigorous evaluation strategies.

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.

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.