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

Colson et al. BMC Medicine (2015) 13:69 DOI 10.1186/s12916-015-0308-5 Medicine for Global Health RESEARCH ARTICLE Open Access 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 Katherine Ellicott Colson1, Laura Dwyer-Lindgren2, Tom Achoki2,3, Nancy Fullman2, Matthew Schneider4, Peter Mulenga5, Peter Hangoma6,7, Marie Ng2, Felix Masiye2,7 and Emmanuela Gakidou2* 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. Keywords: Coverage, Indicators, Inequalities, Maternal and child health, Subnational benchmarking, Zambia * Correspondence: 2 Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA Full list of author information is available at the end of the article © 2015 Colson et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Colson et al. BMC Medicine (2015) 13:69 Background Achievement of universal health coverage (UHC) is a primary goal for an increasing number of health systems worldwide and has been proposed as a key objective for the post-2015 development agenda [1]. UHC aims to provide all people with the high-quality health services they need without the risk of financial hardship from out-ofpocket expenses [2]. Included in UHC is the goal of reducing inequalities within countries, and this has led to an increased focus on within-country inequalities in low- and middle-income countries (LMICs) [3-6]. National gaps in UHC are closely related to inequalities in intervention coverage within countries [7,8]. While much progress has been made in reducing maternal and child mortality in the past two decades [9], many countries are lagging behind in the delivery of life-saving interventions and would benefit from intensified actions targeted to the worst-off and hardest-to-reach populations [10]. To inform these efforts, timely and accurate information is needed, and demand for the measurement of subnational coverage in maternal and child health (MCH) and for analysis of time trends in subnational inequality is increasing [11,12]. Information on subnational levels and trends in health in LMICs is limited but growing. To date, most studies and global monitoring systems have focused on withincountry inequalities by wealth indices, education, gender, or urban residence [6-8,12-27]. While this literature has been immensely important in identifying strikingly large inequalities and informing policy in many countries, gathering information on variation by geographic subunits has been under-prioritized. Subnational benchmarking has been instrumental in decision-making in high-income countries [28-32], but explicit comparisons of performance across subunits over time remain uncommon in much of the developing world. The Countdown to 2015 group has routinely tracked progress and equity in MCH intervention coverage for 75 countries since 2005, but reports incorporating health measures at subnational geographic levels only began in 2010 [33]. Several studies, most commonly in India, have quantified coverage and outcomes at the regional [33-42] and first administrative levels [43-61]; however, most examine only one indicator, do not evaluate trends over time, or are not explicitly targeted to policymakers interested in local benchmarking for their countries. Even fewer studies have explored the geographic distributions for indicators below the first administrative level [62-76], which is arguably of greater policy relevance [77]. Mexico was the first LMIC country to implement subnational benchmarking of effective coverage [48,78-80] and to then have these data feed into policy decisions, demonstrating how locally-relevant data can be used to inform health policymaking. In recent years, Zambia has demonstrated multistakeholder commitment to UHC and equity in health Page 2 of 14 service delivery [81-84]. The country’s National Health Strategic Plan 2011-2015 [82] diverges from previous plans in its emphasis on UHC and overall health system strengthening rather than vertical programs. Zambia has successfully scaled up many priority MCH interventions in the past two decades [82]. However, previous studies have focused on national trends and have not explored within-country inequalities. Accurate, timely, subnational information on intervention coverage is needed to (...truncated)