The Countdown country case studies used mixed methods to comprehensively assess why and how selected countries in Asia, Latin America and sub-Saharan Africa achieved or failed to meet MDGs 4 and 5. A standard framework and methodology were applied for each case study country, which enabled us to systematically review findings and identify key lessons learned.
Seven of the 10 case study countries (China, Peru, Malawi, Bangladesh, Ethiopia, Niger and Tanzania) achieved MDG 4 to reduce childhood mortality, with particular gains seen after the year 2000, and in deaths between the ages of 1 and 59 months. Neonatal mortality gained attention from the mid-2000s, and improved more slowly. There was also progress, although to a slightly lesser degree, toward reducing maternal mortality (MDG 5a), particularly in Afghanistan, Bangladesh, China and Ethiopia. These findings are similar to those reported for the full Countdown project [
1] and elsewhere in the literature [
6,
8].
Success in scaling up interventions delivered in communities and via primary health care system
The case study countries were most successful in scaling up interventions that can be delivered via the primary health care system and in communities, especially child health interventions. There has been widespread implementation of high-impact interventions that can be administered via low levels of the health system, especially for child health. A prime example of this is childhood vaccinations, which began decades ago with the EPI programme, now has broad global support, including substantial financing, and a robust evidence base [
30,
31], and includes newer vaccines for pneumococcal disease, rotavirus, and
Haemophilus influenzae type B (Hib). The LiST analyses suggest that the scale-up of immunisations, especially these newer vaccines, may have been associated with many of the post-neonatal infant and childhood lives saved in the case study countries by the year 2012.
The Countdown case studies suggest mechanisms for improving equity, such as in Peru, where the country’s pro-poor and targeted implementation strategy of childhood immunisation increased equity in health outcomes. The Pakistan case study highlighted the potential riskiness of tightly focusing on a single intervention: the recent emphasis on polio eradication was cited as a detriment to uptake of routine childhood immunisations [
19].
The case study countries’ initiatives to strengthen lower levels of the health system, including community-based programmes and strengthening cadres of lower-level health workers, were also seen as important for improving access to key interventions. For example, although not specifically analysed here, the Niger case study discussed how investments into universal primary health care, including health system strengthening and introducing a new cadre of community health workers, were key factors in the country’s improvement in child survival [
4].
Although there is robust evidence on the importance of meeting the need for family planning [
32,
33], which can often be achieved via the primary health care system or at the community level, this was generally not explored in the case studies – with the exception of the Tanzania case study, which noted the highly variable commitment to, and implementation of, reproductive health programmes since the 1980s [
11].
Variable and lesser increases in coverage of interventions that must be delivered through middle- and higher-level facilities
Interventions delivered via higher-tiered facilities as part of a functioning health system also have persisting equity gaps and have obtained less external support. A key example of this is SBA, which had the most variable level of coverage among all the indicators, as well as the largest equity gaps, which echoes global Countdown findings [
1].
The case studies showed that supportive programmes and policies arrived later for maternal and neonatal interventions, corresponding to a global delay in attention for these issues [
34]. This may reflect the lack of clear, universally agreed-upon strategies for maternal and neonatal care, despite repeated proposals and an evidence base on effective interventions [
35‐
40]. This lack of a global consensus saw a parallel in the country case studies – which, for example, reported a variety of approaches to improving neonatal health, from scaling up neonatal resuscitation and Kangaroo Mother Care in Tanzania, to implementing a community-based newborn care model in Ethiopia and Malawi.
The case study results are also consistent with the evidence base showing that there may be a limit to how much a country’s U5MR may be lowered if its NMR remains high. Continued improvements in childhood survival may also require more complex interventions, e.g., treatment coverage for pneumonia and diarrhoeal disease as well as improved nutrition programmes, and these lagged over the study period in case study countries. [
1]. The global health community must emphasise further improvements in these areas.
Health system constraints, including health worker shortages, were identified by the case study countries as a major barrier to achieving the MDGs, as has been reported elsewhere in the literature [
41], particularly for decreasing maternal and neonatal mortality [
13,
42,
43]. Although several of the case studies cited poor quality of care as a potential limiting factor to progress [
44‐
47], this is difficult to quantify and was not explored empirically in these case studies. This is an area where future research is clearly needed.
Governments, in partnership with the donor community, must continue focusing on health system strengthening. The Sustainable Development Goals’ framework promotes the achievement of universal health care, which requires emphasis on improving health systems, particularly in countries faced with an unfinished agenda of high maternal and child mortality coupled with increases in non-communicable diseases.
Political, economic and social factors contributed to MDG progress
Political, social and economic factors enabled progress in RMNCH, though the extent is difficult to assess and quantify. These findings are consistent with the emphasis on multi-sectoral approaches to addressing mortality and development in the new Sustainable Development Goals [
48].
It is clear from the literature that social and economic development, as well as political context and shifts across non-health sectors, influenced health outcomes and affected the implementation of health policies and programmes including the MDGs [
49‐
51]. The case study countries experienced many political, economic and social changes during the MDG era, and nearly all the case studies discussed the importance of context in influencing progress. The Bangladesh case study, although not included in this comparative content analysis, also showed both health and non-health sector factors (such as improvements in household wealth and women’s education) were crucially important in explaining reductions in maternal mortality [
5].
The case studies indicate that changes in both context and coverage contribute to improved maternal, newborn and child survival. However, further research is needed to precisely attribute their relative contributions in each setting. For example, the case study LiST analyses did not entirely predict the actual survival improvements seen since 2000: it accounted for 80 % of the reported mortality reduction in Malawi over this period, 73 % in Peru, 51 % in Ethiopia, and 39 % in Tanzania. This may be because LiST analyses do not capture all coverage-related changes that may be relevant for mortality decline. They also do not model the role of non-intervention factors, such as infrastructure, economic development, or changes in social and demographic determinants such as education [
52,
53] – which are likely also important for mortality reduction.
An important example of the complex interplay of policies and context with health outcomes is childhood nutritional status. Several case study countries with good progress on stunting took multi-sectoral approaches to addressing this problem, such as introducing reforms in the agricultural sector coupled with nutrition-specific programmes delivered through the health sector, as well as large gains in the coverage of improved water and sanitation. The Niger case study also hypothesised that its multipronged approach to addressing under-nutrition – including both ongoing and emergency services – was an important factor in reducing childhood mortality [
4]. Effective mechanisms to reduce under-nutrition are crucially important, as it is estimated that this is the cause of 45 % of all deaths among children under age 5 [
54].
Measurement is key for effective implementation and monitoring of global initiatives
These results underscore the importance of measurement for the effective implementation and monitoring of global initiatives like the MDGs and now, going forward, the Sustainable Development Goals.
The Countdown initiative, including the case study analyses, have emphasised the centrality of high-quality data for evaluating progress, including identifying lessons learned and remaining gaps, and for programme monitoring purposes. Although Countdown and others have helped generate momentum for improved measurement and accountability globally and in some countries, there is still a long way to go. Data collection has increased for many indicators [
1], but remains a challenge in many countries, particularly those that lack vital registration systems; only one case study country (Peru) contributed vital registry data to the latest WHO maternal mortality estimate. Although some interventions may be comparatively well-monitored, such as immunisations (for which data systems often exist to track antigen-specific coverage at a sub-national level, as well as information on vaccine financing, supply chain issues such as stock-outs, etc.), other domains are less well understood. An important example is neonatal mortality, which is inconsistently defined and measured across settings (including how intrapartum stillbirths are classified, as well as when and how births are recorded), when it is measured at all.
Reliable, frequent and timely data on the coverage and equity of interventions, and on health outcomes, can inform policy adoption and implementation of programmes. Regional- or district-level information can be used to guide implementation, and to measure progress [
55]. Such data can also be used to inform research endeavours, such as the LiST analyses included here, which themselves can inform policy-making and priority-setting. Additionally, mixed methods research approaches, like the Countdown case studies, are an important means for going beyond summary indicators, and assessing the “how” and “why” of progress (or not). Such studies should continue to be undertaken during the Sustainable Development Goals era.
Information availability and data democratisation can enable the engagement of a wide range of stakeholders in discussions about health policies and programmes. The case studies demonstrate that data collection, analysis and synthesis are only the first steps in promoting data use by decision-makers and advocates for action. Some of the case study countries, such as Tanzania, engaged local stakeholders in discussions about the data and progress toward MDGs 4 and 5, which helped stimulate local ownership of the results. More work is needed on refining the Countdown case study model so that dissemination efforts lead to greater uptake of findings for programming and planning purposes. Additionally, more work remains to be done on how to incorporate the private sector into case study analyses, to develop a fuller picture of factors driving progress.
Recent discussions have emphasised the importance of data in sustained global and national accountability in achieving future gains in RMNCH, in health more broadly, and in the context of achieving universal health coverage [
56‐
58].
The Countdown case study portfolio has several strengths, including geographic representation from countries in Africa, Asia and South America; a standard evaluation framework, with a mixed methods analysis approach to attempt to capture the complex factors driving progress; and national capacity-building and engagement of a range of stakeholders in the case study process. This last point in particular distinguishes the Countdown case study process as offering a unique, locally-driven perspective on important RMNCH topics.
There were a number of limitations to our study that should be noted. First, there were a small number of case studies conducted and there may have been case selection bias, since the countries were selected on a number of factors that may be correlated with degrees of change, including data availability and in-country capacity to undertake the research. Secondly since the case studies were largely focused on post-neonatal child health outcomes, the content analysis presented in this cross-cutting paper could not robustly examine reproductive, maternal, neonatal, nor adolescent health. This underscores the importance of increasing attention to these parts of the continuum of care, and perhaps more thoroughly integrating research and practice regarding the more neglected areas of reproductive, adolescent, and neonatal health with the generally more successful maternal and child health issues. We were therefore limited in our ability to explore certain hypotheses – particularly since the case study countries were not selected as representative of certain outcomes (as has been done in other research, such as the Success Factors case studies [
59]) so formed a non-systematically heterogeneous dataset. Thirdly, the content analyses were limited to materials made available from the second phase country teams. We aimed to minimise biases by having two investigators separately conduct the content analysis and by vetting our conclusions with the case study team members. However, we note that there were limited data for health information systems, and evaluation of political, governance and leadership aspects, which are crucial to understanding progress and require further analyses [
55]. Lastly, the measurement of many of the quantitative indicators – including mortality outcomes, which are modelled estimates usually based on household-level nationally representative surveys, as well as coverage and equity data, which are based on nationally representative DHS surveys – face limitations such as small sample size and challenges with estimation procedures; implications of this for LiST analysis results are discussed at length elsewhere [
53].