Tom Achoki

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

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.

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

Abstract. 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.

National mortality burden due to communicable, non-communicable, and other diseases in Ethiopia, 1990–2015: findings from the Global Burden of Disease Study 2015

Background Ethiopia lacks a complete vital registration system that would assist in measuring disease burden and risk factors. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) estimates to describe the mortality burden from communicable, non-communicable, and other diseases in Ethiopia over the last 25 years. Methods GBD 2015 mainly used cause of death ensemble modeling to measure causes of death by age, sex, and year for 195 countries. We report numbers of deaths and rates of years of life lost (YLL) for communicable, maternal, neonatal, and nutritional (CMNN) disorders, non-communicable diseases (NCDs), and injuries with 95% uncertainty intervals (UI) for Ethiopia from 1990 to 2015. Results CMNN causes of death have declined by 65% in the last two-and-a-half decades. Injury-related causes of death have also decreased by 70%. Deaths due to NCDs declined by 37% during the same period. Ethiopia showed a faster decline in the burden of four out of the five leading causes of age-standardized premature mortality rates when compared to the overall sub-Saharan African region and the Eastern sub-Saharan African region: lower respiratory infections, tuberculosis, HIV/AIDS, and diarrheal diseases; however, the same could not be said for ischemic heart disease and other NCDs. Non-communicable diseases, together, were the leading causes of age-standardized mortality rates, whereas CMNN diseases were leading causes of premature mortality in 2015. Although lower respiratory infections, tuberculosis, and diarrheal disease were the leading causes of age-standardized death rates, they showed major declines from 1990 to 2015. Neonatal encephalopathy, iron-deficiency anemia, protein-energy malnutrition, and preterm birth complications also showed more than a 50% reduction in burden. HIV/AIDS-related deaths have also decreased by 70% since 2005. Ischemic heart disease, hemorrhagic stroke, and ischemic stroke were among the top causes of premature mortality and age-standardized death rates in Ethiopia in 2015. Conclusions Ethiopia has been successful in reducing deaths related to communicable, maternal, neonatal, and nutritional deficiency diseases and injuries by 65%, despite unacceptably high maternal and neonatal mortality rates. However, the country’s performance regarding non-communicable diseases, including cardiovascular disease, diabetes, cancer, and chronic respiratory disease, was minimal, causing these diseases to join the leading causes of premature mortality and death rates in 2015. While the country is progressing toward universal health coverage, prevention and control strategies in Ethiopia should consider the double burden of common infectious diseases and non-communicable diseases: lower respiratory infections, diarrhea, tuberculosis, HIV/AIDS, cardiovascular disease, cancer, and diabetes. Prevention and control strategies should also pay special attention to the leading causes of premature mortality and death rates caused by non-communicable diseases: cardiovascular disease, cancer, and diabetes. Measuring further progress requires a data revolution in generating, managing, analyzing, and using data for decision-making and the creation of a full vital registration system in the country.

Cohort analysis of treatment outcomes from facility-based and community-based tuberculosis care in Botswana: a cross-sectional survey

Abstract Background Community-based directly-observed treatment short course is a recent addition to the strategies for delivering anti-tuberculosis (TB) treatment in Botswana. The Botswana National Tuberculosis Program aims to have at least 75% of all patients with TB on community TB care (CTBC). However, prior to this study, the treatment outcomes had not yet been evaluated. This study aimed to compare the treatment outcomes for patients on CTBC with those on facility-based TB care (FTBC). Methods A retrospective review of TB registers was conducted for a cohort of patients receiving TB treatment between Jan 1 and June 31, 2012, in 14 districts. Data were abstracted on sputum results, age, sex, HIV status, treatment outcome, and options. A sample size of 1000 patients was obtained. The outcome of interest was treatment outcome. It was a binary variable with good (cured, completed, or success) and poor (died, defaulted, or failed) as the outcomes. Data were analysed using STATA SE/12. Findings The study had 511 men and 489 women. Mean age was 35 years (SD 2·7). FTBC accounted for 496 patients, while 504 were on CTBC. Of the patients who received FTBC, 113 (22·8%) were cured, 277 (55·8%) completed treatment, 390 (78·6%) had treatment success, 21 (4·2%) defaulted, 11 (2·2%) failed, and 74 (14·9%) died. Of the patients who received CTBC, 118 (23·4%) were cured, 333 (66·1%) completed treatment, 451 (89·5%) had treatment success, ten (2·0%) defaulted, seven (1·4%) failed, and 36 (7·1%) died. Logistic regression showed that patients on CTBC were 2·3 times more likely to have good treatment outcomes compared with those on FTBC. Older age and HIV-positive status were associated with poor treatment outcomes (odds ratio 0·9752, 95% CI 0·9633–0·9872, p=0·001; and 0·4071, 0·2874–0·5765, p=0·001, respectively). Interpretation CTBC offers better treatment outcomes than FTBC care in the Botswana setting. Results show the urgent need to expand CTBC so as to improve coverage rates. Improvements in TB case finding and stigma reduction in the Botswana context are still needed. Funding This research was funded through the I-TECH Botswana/HRSA Budget.

Proceedings of the International Workshop ‘From Global Burden of Disease Studies to National Burden of Disease Surveillance'

Table of contentsI1 Introduction and aims of the workshop Christa Scheidt-Nave, Thomas Ziese, Judith Fuchs, Dietrich PlassS1 History, concept, and current results of GBD for GermanyTom Achoki, Katherine Leach-Kemon, Peter Speyer, William E. Heisel, Emmanuela Gakidou, Theo VosS2 Methodology of the GBD 2013 Study–Mortality, Morbidity, Risk-FactorsMohammad Hossein ForouzanfarS3 National burden of disease surveillance examples of good practice: the case of Public Health EnglandJürgen C. SchmidtS4 Critical aspects of the burden of disease methodology and country-specific challengesClaudia E. SteinS5 Non-communicable disease surveillance in Germany – public health and data challengesChrista Scheidt-Nave, Elena von der Lippe, Benjamin Barnes, Markus Busch, Nina Buttmann-Schweiger, Judith Fuchs, Christin Heidemann, Klaus Kraywinkel, Enno Nowossadeck, Thomas ZieseS6 Different approaches in estimating the burden of communicable diseases using the examples of the healthcare associated infections and influenzaUdo Buchholz, Matthias an der Heiden, Tim Eckmanns, Sebastian HallerS7 Behavioral and environmental attributable risk estimationMohammad Hossein ForouzanfarS8 Environmental Burden of Disease (EBD) in Germany – past achievements and future perspectivesDietrich Plass, Myriam Tobollik, Dagmar Kallweit, Dirk WintermeyerC1 Conclusions of the workshopChrista Scheidt-Nave, Thomas Ziese, Judith Fuchs, Dietrich Plass

The imperative for systems thinking to promote access to medicines, efficient delivery, and cost-effectiveness when implementing health financing reforms: a qualitative study

BackgroundHealth systems across Africa are faced with a multitude of competing priorities amidst pressing resource constraints. Expansion of health insurance coverage offers promise in the quest for sustainable healthcare financing for many of the health systems in the region. However, the broader policy implications of expanding health insurance coverage have not been fully investigated and contextualized to many African health systems.MethodsWe interviewed 37 key informants drawn from public, private and civil society organizations involved in health service delivery in Botswana. The objective was to determine the potential health system impacts that would result from expanding the health insurance scheme covering public sector employees. Study participants were selected through purposeful sampling, stakeholder mapping, and snowballing. We thematically synthesized their views, focusing on the key health system areas of access to medicines, efficiency and cost-effectiveness, as intermediate milestones towards universal health coverage.ResultsParticipants suggested that expansion of health insurance would be characterized by increased financial resources for health and catalyze an upsurge in utilization of health services particularly among those with health insurance cover. As a result, the health system, particularly within the private sector, would be expected to see higher demand for medicines and other health technologies. However, majority of the respondents cautioned that, realizing the full benefits of improved population health, equitable distribution and financial risk protection, would be wholly dependent on having sound policies, regulations and functional accountability systems in place. It was recommended that, health system stewards should embrace efficient and cost-effective delivery, in order to make progress towards universal health coverage.ConclusionDespite the prospects of increasing financial resources available for health service delivery, expansion of health insurance also comes with many challenges. Decision-makers keen to achieve universal health coverage, must view health financing reform through the holistic lens of the health system and its interactions with the population, in order to anticipate its potential benefits and risks. Failure to embrace this comprehensive approach, would potentially lead to counterproductive results.

Technical and scale efficiency in the delivery of child health services in Zambia: results from data envelopment analysis

Objective Despite tremendous efforts to scale up key maternal and child health interventions in Zambia, progress has not been uniform across the country. This raises fundamental health system performance questions that require further investigation. Our study investigates technical and scale efficiency (SE) in the delivery of maternal and child health services in the country. Setting The study focused on all 72 health districts of Zambia. Methods We compiled a district-level database comprising health outcomes (measured by the probability of survival to 5 years of age), health outputs (measured by coverage of key health interventions) and a set of health system inputs, namely, financial resources and human resources for health, for the year 2010. We used data envelopment analysis to assess the performance of subnational units across Zambia with respect to technical and SE, controlling for environmental factors that are beyond the control of health system decision makers. Results Nationally, average technical efficiency with respect to improving child survival was 61.5% (95% CI 58.2% to 64.8%), which suggests that there is a huge inefficiency in resource use in the country and the potential to expand services without injecting additional resources into the system. Districts that were more urbanised and had a higher proportion of educated women were more technically efficient. Improved cooking methods and donor funding had no significant effect on efficiency. Conclusions With the pressing need to accelerate progress in population health, decision makers must seek efficient ways to deliver services to achieve universal health coverage. Understanding the factors that drive performance and seeking ways to enhance efficiency offer a practical pathway through which low-income countries could improve population health without necessarily seeking additional resources.

Global, regional, and national levels of maternal mortality, 1990-2015

BACKGROUND In transitioning from the Millennium Development Goal to the Sustainable Development Goal era, it is imperative to comprehensively assess progress toward reducing maternal mortality to identify areas of success, remaining challenges, and frame policy discussions. We aimed to quantify maternal mortality throughout the world by underlying cause and age from 1990 to 2015. METHODS We estimated maternal mortality at the global, regional, and national levels from 1990 to 2015 for ages 10-54 years by systematically compiling and processing all available data sources from 186 of 195 countries and territories, 11 of which were analysed at the subnational level. We quantified eight underlying causes of maternal death and four timing categories, improving estimation methods since GBD 2013 for adult all-cause mortality, HIV-related maternal mortality, and late maternal death. Secondary analyses then allowed systematic examination of drivers of trends, including the relation between maternal mortality and coverage of specific reproductive health-care services as well as assessment of observed versus expected maternal mortality as a function of Socio-demographic Index (SDI), a summary indicator derived from measures of income per capita, educational attainment, and fertility. FINDINGS Only ten countries achieved MDG 5, but 122 of 195 countries have already met SDG 3.1. Geographical disparities widened between 1990 and 2015 and, in 2015, 24 countries still had a maternal mortality ratio greater than 400. The proportion of all maternal deaths occurring in the bottom two SDI quintiles, where haemorrhage is the dominant cause of maternal death, increased from roughly 68% in 1990 to more than 80% in 2015. The middle SDI quintile improved the most from 1990 to 2015, but also has the most complicated causal profile. Maternal mortality in the highest SDI quintile is mostly due to other direct maternal disorders, indirect maternal disorders, and abortion, ectopic pregnancy, and/or miscarriage. Historical patterns suggest achievement of SDG 3.1 will require 91% coverage of one antenatal care visit, 78% of four antenatal care visits, 81% of in-facility delivery, and 87% of skilled birth attendance. INTERPRETATION Several challenges to improving reproductive health lie ahead in the SDG era. Countries should establish or renew systems for collection and timely dissemination of health data; expand coverage and improve quality of family planning services, including access to contraception and safe abortion to address high adolescent fertility; invest in improving health system capacity, including coverage of routine reproductive health care and of more advanced obstetric care-including EmOC; adapt health systems and data collection systems to monitor and reverse the increase in indirect, other direct, and late maternal deaths, especially in high SDI locations; and examine their own performance with respect to their SDI level, using that information to formulate strategies to improve performance and ensure optimum reproductive health of their population. FUNDING Bill & Melinda Gates Foundation.