Abstract
BackgroundAchieving 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.MethodsWe 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.ResultsNational 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.ConclusionsZambia 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.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-015-0308-5) contains supplementary material, which is available to authorized users.
Highlights
Achieving universal health coverage and reducing health inequalities are primary goals for an increasing number of health systems worldwide
Included in universal health coverage (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) [3,4,5,6]
We did not include immunization coverage estimates constructed by pairing data on the number of doses administered with population figures, because, in contrast with survey-based estimates, such measures are often subject to significant numerator and denominator bias which are likely exacerbated at the district level [87]
Summary
Achieving universal health coverage and reducing health inequalities are primary goals for an increasing number of health systems worldwide. 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]
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