Policy & practice Success factors for reducing maternal and child mortality 102484 Shyama Kuruvilla,a Julian Schweitzer,b David Bishai,c Sadia Chowdhury,d Daniele Caramani,e Laura Frost,f Rafael Cortez,g Bernadette Daelmans,h Andres de Francisco,a Taghreed Adam,i Robert Cohen,c Y Natalia Alfonso,c Jennifer Franz-Vasdeki,j Seemeen Saadat,g Beth Anne Pratt,f Beatrice Eugster,e Sarah Bandali,k Pritha Venkatachalam,l Rachael Hinton,a John Murray,m Sharon Arscott-Mills,n Henrik Axelson,o Blerta Maliqi,h Intissar Sarker,g Rama Lakshminarayanan,a Troy Jacobs,p Susan Jacks,q Elizabeth Mason,h Abdul Ghaffar,i Nicholas Mays,r Carole Preserna & Flavia Bustreoh on behalf of the Success Factors for Women’s and Children’s Health study groups Abstract Reducing maternal and child mortality is a priority in the Millennium Development Goals (MDGs), and will likely remain so after 2015. Evidence exists on the investments, interventions and enabling policies required. Less is understood about why some countries achieve faster progress than other comparable countries. The Success Factors for Women’s and Children’s Health studies sought to address this knowledge gap using statistical and econometric analyses of data from 144 low- and middle-income countries (LMICs) over 20 years; Boolean, qualitative comparative analysis; a literature review; and country-specific reviews in 10 fast-track countries for MDGs 4 and 5a. There is no standard formula – fast-track countries deploy tailored strategies and adapt quickly to change. However, fast-track countries share some effective approaches in addressing three main areas to reduce maternal and child mortality. First, these countries engage multiple sectors to address crucial health determinants. Around half the reduction in child mortality in LMICs since 1990 is the result of health sector investments, the other half is attributed to investments made in sectors outside health. Second, these countries use strategies to mobilize partners across society, using timely, robust evidence for decision-making and accountability and a triple planning approach to consider immediate needs, long-term vision and adaptation to change. Third, the countries establish guiding principles that orient progress, align stakeholder action and achieve results over time. This evidence synthesis contributes to global learning on accelerating improvements in women’s and children’s health towards 2015 and beyond. ternal deaths occur, most from preventable causes.2–4Progress Introduction varies widely across countries, even where levels of income are Worldwide, accelerated progress is required to achieve Millen- similar.8 There is a need for evidence on why some low- and nium Development Goals (MDGs) 4 (reduce child mortality) and middle-income countries (LMICs) do better than others in 5 (improve maternal health) as highlighted in the United Nations preventing maternal and child deaths and on the strategies they Secretary-General’s Global Strategy for Women’s and Children’s use to accelerate progress.8,9 Health.1 There have been substantial achievements from 1990 This knowledge gap prompted discussions at the Partnership (the baseline for the MDGs) to date. Child and maternal deaths for Maternal, Newborn & Child Health Partners’ Forum in 2010, decreased globally by around 50%, and contraceptive prevalence leading to a three-year multidisciplinary, multicountry series of increased from 55% to 63%.2–4 There is consensus on evidence- studies on Success Factors for Women’s and Children’s Health based, cost-effective investments and interventions 5,6 and on (hereafter referred to as the Success Factors studies).10 The Suc- enabling health and multisectoral policies.7 cess Factors studies were supported by the Partnership for Ma- Despite these advances, every year 6.6 million children die ternal, Newborn & Child Health, the World Health Organization before five years of age (44% as newborns) and 289  000 ma- (WHO), the World Bank and the Alliance for Health Policy and a Partnership for Maternal, Newborn & Child Health, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland. b Results for Development Institute, Washington, United States of America (USA). c Johns Hopkins Bloomberg School of Public Health, Baltimore, USA. d BRAC Institute of Global Health, Dhaka, Bangladesh. e University of St Gallen, St Gallen, Switzerland. f Global Health Insights, New York, USA. g World Bank, Washington, USA. h World Health Organization, Geneva, Switzerland. i Alliance for Health Policy and Systems Research, Geneva, Switzerland. j Independent Consultant, Seattle, USA. k Options Consultancy, London, England. l Cambridge Economic Policy Associates, Delhi, India. m Independent Consultant, Iowa City, USA. n ICF International, Fairfax, USA. o World Health Organization, Phnom Penh, Cambodia. p USAID, Washington, USA. q University of Otago, Dunedin, New Zealand. r London School of Hygiene & Tropical Medicine, London, England. Correspondence to Shyama Kuruvilla (email: kuruvillas@who.int). (Submitted: 4 March 2014 – Accepted: 7 May 2014 – Published online: 5 June 2014 ) Bull World Health Organ 2014;92:533–544 | doi: http://dx.doi.org/10.2471/BLT.14.138131 533 Policy & practice Success factors for reducing maternal and child mortality Shyama Kuruvilla et al. Systems Research, working closely with Box 1. Analytical framework for the Success Factors for Women’s and Children’s Health ministries of health, academic institutions study series and other partners.10 The studies sought to understand what works to support Independent variables countries’ progress towards the MDGs Health sector: investments in health systems with universal access to services and to inform the post-2015 goals and • Service delivery (e.g. skilled birth attendance, contraceptive prevalence rate) strategies under preparation. • Health workforce (e.g. doctors per 1 000 population) • Information (e.g. health information systems) Methods • Medical products, vaccines and technologies (e.g. measles vaccine coverage) • Financing (e.g. total health expenditure per capita) Analytical framework • Health systems governance (e.g. adoption of enabling policies for women’s and children’s The analytical framework for the Success health) Factors studies (Box 1) builds on the UN Sectors outside health: investments and policies that are health-enhancing Millennium Project’s “clusters of public • Promoting vibrant rural and urban communities, including through infrastructure investments and policies”11 and WHO’s development (e.g. electricity: kilowatt hours/capita) “health systems building blocks”.12 We • Ensuring universal enrolment and completion of primary education and expanded access used literature reviews and expert con- to post-primary and higher education (e.g. girls’ primary school enrolment) sultations to identify over 250 related • Improving environmental management (e.g. access to clean water) variables to develop the database for these studies.13 • Building national capacities in science, technology and innovation (e.g. number of scientific publications, Global Innovation Index) Countries included Cross-sectoral factors affecting health The statistical and econometric analyses • Population dynamics (e.g. total fertility rate, % urban population) included all 144 countries that the World • Women’s political and socioeconomic participation (e.g. % female parliamentarians) Bank designated as LMICs in 1990. For • Overcoming inequalities and realizing rights (e.g. Gini; ratification of human rights treaties) the in-depth country reviews, we selected • Economic development (e.g. GDP per capita) 10 of the 75 “Countdown to 2015” high- • Good governance across sectors (e.g. World Governance Index, Global Leadership and mortality burden countries:8 Bangladesh, Organizational Behaviour Effectiveness (GLOBE) scores) Cambodia, China, Egypt, Ethiopia, Lao People’s Democratic Republic, Nepal, Dependent variables Peru, Rwanda and Viet Nam. We refer Main outcome variables – MDGs 4 and 5a to these countries as “fast-track” because • Maternal mortality ratio they were on track in 2012 to achieve • Under-five mortality rate both MDGs 4 and 5 ahead of comparable countries. (Other Countdown countries Additional outcome variables such as Liberia and the Niger are achiev- • Other health status indicators, including neonatal mortality rate, global burden of ing fast-track progress to reduce child communicable and noncommunicable diseases, violence and injuries and nutritional status mortality. If we consider all 144 LMICs, GDP: gross domestic product; MDG: Millennium Development Goal. rather than only the 75 Countdown coun- Note: The analytical framework builds on the UN Millennium Project’s “clusters of public investments and tries, additional fast-track countries for policies”11 and WHO’s “health systems building blocks”.12 reducing both maternal and child mor- tality include the Maldives and Turkey). This article is an evidence syn- was thematic saturation;22 that is, when thesis across the five primary techni- existing thematic categories could accom- Research methods cal papers. 14–18 To synthesize the evi- modate new findings but no new themes The Success Factors studies teams devel- dence, we used a multi-grounded theory were required to categorize the data. oped five primary technical papers based approach20(Fig. 1). We first categorized the To ensure research quality and ro- on: (i) quantitative mapping of trends;14 data deductively using the studies’ analyti- bustness of the findings we used a trian- (ii) econometric modelling;15 (iii) Bool- cal framework (Box 1). We then refined gulation of methods, with an experienced, ean, Qualitative Comparative Analysis;16 the thematic categories, inductively and multidisciplinary team and a series of (iv) literature review with narrative iteratively, using a triangulate to vali- internal and external reviews of the study evidence synthesis;17 and (v) country- date approach across the qualitative and design, ethics and findings.10 specific literature and data reviews in 10 quantitative methods. Using a narrative fast-track countries.18 synthesis approach21 we anchored each As a following step, ministries of thematic category to data from the Success Results health will convene multistakeholder Factors studies; for example, with statisti- A strong pattern of findings emerges across policy review meetings in the 10 se- cal trends, econometric models or country the Success Factors studies.14–18 Those lected fast-track countries to document examples. Through regular discussions LMICs which are making fast progress milestones on each country’s pathway to with the different study teams, we reached deploy strategies tailored to their unique improving women’s and children’s health. a shared understanding and agreement situations and adapt quickly to change. Each country will subsequently publish a on the emerging narrative synthesis. The While there is no standard formula, fast- policy report.19 narrative synthesis continued until there track countries are moving ahead in three 534 Bull World Health Organ 2014;92:533–544| doi: http://dx.doi.org/10.2471/BLT.14.138131 Policy & practice Shyama Kuruvilla et al. Success factors for reducing maternal and child mortality are available from: http://www.who.int/ Fig. 1. Multi-grounded theory approach used to synthesize the studies’ findings bulletin/volumes/92/7/14-138131). For example, countries that are making acceler- Deductive analysis Inductive analysis ated progress towards MDGs 4 and 5a are Theory or hypothesis driven; categories Empirically driven analysis; categories also making progress on most of the other based on the existing literature built from the study findings MDGs, e.g. to decrease poverty and hunger and improve education, gender equality and environmental sustainability (Fig. 7). Triangulate to Economic growth underpins mul- validate tisector progress, but it alone is not suf- Considering different data sources and ficient. The Success Factors econometric categorizations analysis by Bishai et al. indicates that gross domestic product (GDP) per capita accounted on average for only 12% of the reduction in child mortality in LMICs Multigrounded theory synthesis between 1990 and 2010.15 Further, the Synthesis of concepts, theories or hypotheses based relationship between economic growth on theoretical saturation related to the study findings and health outcomes varies across coun- tries. Many LMICs (e.g. India, Nigeria) Adapted from Goldkuhl & Cronholm (2010).20 experienced fast economic growth, but did not make commensurate progress on Fig. 2. Factors involved in declining child mortality in 144 low- and middle-income maternal and child health. Others (e.g. countries,1990–2010 Bangladesh, China and Rwanda) made good progress while following diverse Women’s political and socioeconomic participation economic strategies. 100% (e.g. % seats held by women in national parliaments) Health-sector investments accounted for around half the mortality reduction in Economic development (e.g. log GDP per capita) children under five years between 1990 Factor and 2010 (Fig. 2). High-impact interven- impact 24% 0% tions and systems strengthening were im- changes 100% portant; e.g. for immunization and other Health systems (e.g. immunization: log odds measles child health interventions, skilled birth vaccination coverage) attendance and maternal and newborn Factor care, and family planning.15 The remain- level 76% ing gains resulted from health-enhancing changes Health systems (e.g. skilled birth attendance log odds) investments in other sectors; e.g. from Women’s political and socioeconomic participation improved levels of education, women’s (e.g. % seats held by women in national parliaments) political and socioeconomic participation Population dynamics (e.g. total fertility rate reductions) and environmental management (e.g. for Education (e.g. female primary school enrolment log access to clean water), and reduced levels odds, lag 10 years) of fertility and poverty. Income inequalities Environmental management (e.g. access to clean water log odds) within countries had a negative impact on Economic development (e.g. GDP per capita log) child mortality (Fig. 2). The proportions of factors varied by country, and with the 0% Income inequality (e.g. Gini - negative effect) statistical models used, but the core set of multisector factors contributing to acceler- GDP: gross domestic product. Note: Factor impact changes refer to the impact of these factors increasing between 1990 and 2010, for ated progress was the same.15 example, a given per capita GDP in 2010 was associated with a lower under five years of age mortality The Boolean analysis highlighted a rate than the same level of per capita GDP in 1990.15 Factor level changes refer to improvements in the similar core set of multisector factors that levels or coverage of factors between 1990 and 2010. display high levels of necessity, meaning Adapted from Bishai et al. (2014).15 that countries cannot make fast-track progress without addressing a range of main areas to reduce maternal and child policies, align action and steer progress factors within and beyond the health mortality: progress across multiple sectors (hereafter guiding principles). sector (Table 1).16 The Boolean analysis to address crucial health determinants findings also indicate that no single Multisector progress (hereafter multisector progress); strate- factor approaches a sufficiency score of gies that can catalyse accelerated progress The Success Factors studies find that the 1.0, which on its own would effectively and maximize health outcomes (hereafter key to progress in fast-track countries is guarantee fast-track progress, again em- catalytic strategies); and principles – based improvement across a range of health de- phasizing the importance of progress on principles of human rights and devel- terminants within and beyond the health across sectors. opment effectiveness and political and sector (Fig. 2, Fig. 3, Fig 4, Fig. 5, Fig. 6, The Boolean analysis further explored economic models – that can help shape Fig 7 and Fig. 8, Table 1; Fig 5 and Fig. 6 whether there were specific configurations Bull World Health Organ 2014;92:533–544| doi: http://dx.doi.org/10.2471/BLT.14.138131 535 Policy & practice Success factors for reducing maternal and child mortality Shyama Kuruvilla et al. of factors associated with countries making Fig. 3. Multisector factors in the 75 Countdown to 2015 countries, 1990–2010 fast-track progress. No single configuration of factors proved necessary or sufficient.16 4.1 Instead, results point to a diversity of con- GDP PPP, per capita % growth** 1.2 figurations in different countries associated 1.0 –22.9 with fast-track progress. There were also no Poverty < US$ 2 per day, %* –11.8 –12.6 simple cut-off points, or levels of coverage, associated with fast-track progress, as these 1.5 Government effectiveness index (x10) –0.8 varied depending on country contexts, –2.5 starting levels in 1990 and combined prog- 22.1 Skilled birth attendance, %* 10.1 ress across a core set of multisector factors.16 5.1 The Boolean analyses indicated that 3.1 there were similar results for fast track Doctors per 100 people* 0.4 0.2 progress on maternal mortality reduc- 24.0 tion. However, both the Boolean and Measles immunization, % 16.0 6.1 econometric analyses were limited by the 23.5 fact that the global maternal mortality Prenatal care, %* 11.0 4.5 estimates, e.g. from the Maternal Mortal- –0.1 ity Estimation Inter-agency Group,4 are HIV prevalence, % 2.4 8.3 based on a regression model that includes 8.9 many of the key factors of interest (e.g. Health expenditure per capita, % annual growth 7.4 GDP per capita, total fertility rate, and 4.4 –3.7 skilled birth attendance). Out-of-pocket health spending, % –5.9 Two factors identified as key enablers –1.2 across the quantitative and qualitative 26.8 Sanitation, % access** 9.3 findings in the Success Factors studies are 7.5 good governance and women’s political 20.6 and socioeconomic participation. Clean water, % access 12.7 12.0 –2.1 Good governance Total fertility rate** –1.3 –1.2 Good governance, and particularly control 17.7 of corruption, as measured by the World Contraceptive prevalence, %* 9.5 11.3 Bank’s Worldwide Governance Indica- 17.8 tors,23 is associated with country progress Parliament, % women* 8.5 7.6 (Fig. 3). Ensuring value for money is also 1.4 a key feature of enabling governance, as Female labour force, % participation 3.6 most fast-track countries improved health 4.0 2.3 outcomes despite relatively low levels of Total years schooling, female* 1.8 investment (Fig. 8) resulting in part from 1.8 low GDP per capita and significant politi- 2.0 Total years schooling, both sexes 1.7 cal and economic problems. 1.7 The Success Factors literature review 0.7 Power consumption per capita, MWh** 0.0 found decentralized governance to be an 0.2 enabling factor for accelerated progress.17 7.1 However, the reach, influence and even Roads paved, % 3.7 1.6 definition of decentralized governance 6.9 varies considerably between countries. Published scientific papers annually, 1000s* 0.4 0.1 Rwanda has a highly centralized policy- making approach supported by district- –30.0 –20.0 –10.0 0.0 10.0 20.0 30.0 level planning and implementation.24 In Unweighted means of absolute change between 1990 and 2010 other countries, such as Nepal, geography 10 Fast-track Countdown to 2015 countries (with the fastest rates of both U5MR and MMR reduction) and politics necessitated a much more re- Other Countdown to 2015 countries (65) gionalized approach. Caution is therefore 10 Countdown to 2015 countries with the slowest rates of both U5MR and MMR reduction needed when interpreting decentralized governance as a success factor. * P < 0.05; ** P < 0.01; GDP: gross domestic product; HIV: human immunodeficiency virus; MMR: measles, mumps and rubella; MWh: Mega Watt hour; PPP: purchasing power parity; U5MR: under-five years Women’s participation in politics mortality rate; US$: United States dollars. and workforce Note: P-values estimated using N-way ANOVA comparing fast-track countries with the 65 other countries, (excluding the 10 countries with slower rates of progress), for stronger statistical power. Some values are The Success Factors studies confirm es- scaled by factor of 10 to be comparable on a single chart. In 1990, across the countries, levels for most tablished evidence on the links between factors were not significantly different, except that fast-track countries had significantly lower prenatal better education and improved maternal care, power consumption per capita and Gini coefficient. and child health (Fig. 3 and Fig. 4).14–18 536 Bull World Health Organ 2014;92:533–544| doi: http://dx.doi.org/10.2471/BLT.14.138131 Policy & practice Shyama Kuruvilla et al. Success factors for reducing maternal and child mortality The Success Factors studies further high- Fig. 4. Multisector factors in 144 low- and middle-income countries, 1990–2010 light the importance of women’s political and socioeconomic participation. Fast- track countries have significantly more 3.7 GDP PPP, per capita % growth** 1.8 women parliamentarians (Fig. 3 and 1.0 Fig. 4). In Rwanda, 64% of parliamen- Poverty –17.1 –10.3 tarians are women.19,23 In Lao People’s < US$ 2 per day, % –12.6 Democratic Republic, the proportion of –0.8 women members in the national legisla- Government effectiveness index (x10) 0.2 –2.5 ture tripled between 1990 and 2003, with 12.0 the government explicitly recognizing the Skilled birth attendance, % 8.0 5.1 importance of gender parity and rights 6.2 for women, including through the Law Doctors per 100 people* 1.1 0.2 on the Development and Protection of 20.2 Women (2004).18,25 Measles immunization, % 13.6 6.1 Fast-track countries also had a 22.4 higher average female labour-force par- Prenatal care, %* 11.4 ticipation rate than other “Countdown” 4.5 0.0 countries in 1990 (64% to 54%) and HIV prevalence, % 1.7 this rate still remained higher in 2010 8.3 (Fig. 3). Many fast-track countries (e.g. 10.1 Health expenditure per capita, % annual growth 7.9 Bangladesh, Cambodia, China and Viet 4.4 Nam) developed industries that employ –0.5 Out-of-pocket health spending, % –3.5 large numbers of women.18 The increased –1.2 wages these workers earn are potentially 17.7 available for expenditure on their own Sanitation, % access* 9.3 7.5 health, as well as that of their children 10.5 and families, and further work is needed Clean water, % access 9.6 12.0 to understand these links. –2.0 Total fertility rate** –1.2 Catalytic strategies –1.2 12.0 While fast-track countries deployed Contraceptive prevalence, % 8.3 unique context-specific strategies, the 11.3 7.9 Success Factors studies identified some Parliament, % women 7.6 shared catalytic strategies that these coun- 7.6 2.4 tries used to optimize the use of resources, Female labour force, % participation 3.0 accelerate progress and maximize health 4.0 outcomes. 2.7 Total years schooling, female** 1.9 1.8 Leadership and partnerships 2.4 Total years schooling, both sexes* 1.7 In the fast-track countries, actors across 1.7 society played leadership roles in im- 1.3 proving women’s and children’s health, Power consumption per capita, MWh** 0.3 0.2 sometimes compensating for limited 17.3 government resources. Roads paved, %** 4.2 1.6 In Bangladesh, the government 8.7 partners with nongovernmental orga- Published scientific papers annually, 1000s** 0.4 0.1 nizations, communities and the private sector in the provision of health services. –20.0 –15.0 –10.0 –5.0 0.0 5.0 10.0 15.0 20.0 25.0 In 2010, over half of the births in health Unweighted means of absolute change between 1990 and 2010 facilities occurred in the private sector.26 10 LMICs with the fastest rates of both U5MR and MMR reduction Nongovernmental organizations such Other LMICs (134 countries) as BRAC and the Grameen Foundation 10 LMICs with the slowest rates of both U5MR and MMR reduction cross-subsidize health services with rev- enues from their commercial activities. * P < 0.05; ** P < 0.01; GDP: gross domestic product; HIV: human immunodeficiency virus; LMIC: low- and Telemedicine and mobile phones also middle-income countries; MMR: measles, mumps and rubella; MWh: Mega Watt hour; PPP: purchasing help increase access to health services, power parity; U5MR: under-five years mortality rate; US$: United States dollars. Note: P-values estimated using N-way ANOVA. Some values are scaled by factor of 10 to be comparable particularly for underserved popula- on a single chart. tions.27 Partnerships between communities and service providers in the “Casa Ma- terna” scheme in Peru enable pregnant Bull World Health Organ 2014;92:533–544| doi: http://dx.doi.org/10.2471/BLT.14.138131 537 Policy & practice Success factors for reducing maternal and child mortality Shyama Kuruvilla et al. Fig. 7. A status assessment of 10 fast-track countries’ progress towards the Millennium Development Goals, early 2014 Millenium Bangladesh Cambodia China Egypt Ethiopia Lao People’s Nepal Peru Rwanda Viet Nam Develoment Goals Democratic Republic Poverty on track on track target met target met on track on track target met target met off track target met MDG 1 Hunger target met target met target met target met on track off track target met target met on track target met MDG 2 Education target met on track target met on track on track on track on track on track target met target met MDG 3 Gender disparity target met on track target met on track on track on track target met on track target met on track MDG 4 Child mortality target met target met target met target met target met off track target met target met on track on track Maternal mortalitya on track target met on track on track on track on track target met on track on track target met MDG 5 Family planning on track on track on track on track on track on track off track target met on track target met HIV target met off track n/a target met off track off track off track off track target met off track MDG 6 Tuberculosis target met target met target met target met target met target met target met target met target met off track Water target met target met target met target met on track target met target met on track off track target met MDG 7 Sanitation on track off track target met target met off track target met off track on track on track target met MDG 8 Stabilizing debtb on track on track on track off track on track on track off track off track off track on track HIV: human immunodeficiency virus; MDG: Millennium Development Goals; N/A: not applicable; UNDP: United Nations Development Programme. a  MDG 5b: As there are no clear “on track” criteria for Target 5b (Unmet need for family planning, total, percentage), across all the countries we used the criteria established based on Bangladesh country report that marked progress as “on track” if the 2015 projected figure was 8% or less, or the percentage change between base and current year was 35% or higher. b  MDG 8: As there are no clear “on track” criteria for MDG 8, countries are marked as “on track” if 2015 projected figure for the indicator – debt service as percentage of exports and net income – is equal to zero. c Lao People’s Democratic Republic is currently considered “off track” for MDG 4 based on 2012 data; however, it was “on track” for MDG 4 based on 2010 reporting and when the fast-track countries were selected for analysis. Note: The table provides a snapshot of progress towards each MDG based on one or two key target indicators for each MDG. Developed from UNDP MDG country progress reports and MDG database (available from: http://mdgs.un.org/unsd/mdg/Default.aspx) women in remote rural areas to await to performance-based financing pro- Decision-making and accountability delivery in dedicated maternity centres. grammes, resulting in increased use and Transportation to hospitals is available if Despite limited resources, fast-track better quality of family planning services.34 they need specialist care. These centres countries have developed capacities to Testing innovative, evidence-based also offer culturally sensitive birthing collect, analyse and use robust evidence to approaches to address context-specific options to promote utilization. Between inform policy, investment, implementa- needs has also been critical to progress. 2005 and 2010, this scheme contributed tion and accountability. Nepal, for example, has emphasized to the halving of maternal mortality in The Success Factors literature review testing and scaling up community-based the Ayacucho district.28 highlights the value of evidence-based approaches.35 In Cambodia, multistakeholder tools and health information systems.17 Approach to sustain progress partnerships promoted maternal and Save the Children’s “Saving Newborn child health through behaviour-change Lives” programme demonstrated the Fast-track countries achieve rapid prog- communication campaigns. In 2004, value of decision-support tools, such as ress by adopting a triple planning ap- the BBC World Service Trust launched the Lives Saved Tool, now included in proach that focuses on: (i) quick wins a mass-media campaign using television the United Nations One Health Tool, to with targeted or emergency strategies series and radio broadcasts to promote support national planning.31 to address immediate, urgent needs; maternal and child health themes such as In Ethiopia, scorecards are used at all (ii) longer-term gains from building exclusive breastfeeding.29 Knowledge and levels of the health system – community, strong, sustainable systems to achieve practice improved and national exclusive regional, and national – to monitor prog- a long-term vision; and (iii) adaptation breastfeeding rates increased from 11% in ress on women’s and children’s health. The to address change and sustain progress. 2000 to 60% in 2005 and to 74% in 2010.29 government views scorecards as a power- After the genocide, in 1994, Rwanda In Ethiopia, the National Nutrition ful tool to track progress and identify deployed community health workers and Programme uses multisector partnerships inequities in health services delivery.32 volunteers for urgent health needs. At the to tackle undernutrition and includes so- In China, the National Maternal and same time the country promoted invest- cial protection, food security, community Child Health Routine Reporting System ments in a long-term vision to build its nutrition programmes, micronutrient covers the whole population.33 A national professional health workforce and health supplementation, treatment of severe system of contracts and agreements for facilities with medical colleges, referral acute malnutrition and a package of free health providers and administrators, hospitals and international academic and health services. The country is now on monitors quality and service delivery at professional collaborations.36,37 track to achieve MDG 1c to reduce hun- all levels.18,19 Progress is not always unidirectional ger. Child stunting rates dropped from In Egypt, quality-of-care indicators and countries need to adapt their strategies 57% in 2000 to 44% in 2010.18,30 (e.g. on patient satisfaction) were added to sustain it. The Success Factors literature 538 Bull World Health Organ 2014;92:533–544| doi: http://dx.doi.org/10.2471/BLT.14.138131 Fig. 8. Total health expenditure per capita worldwide and in 10 fast-track countries, 2012 Shyama Kuruvilla et al. China Ethiopia Lao PDR Viet Nam Nepal Peru Egypt Bangladesh US$ per capita annual health expenditure Bull World Health Organ 2014;92:533–544| doi: http://dx.doi.org/10.2471/BLT.14.138131 <25 26–50 Rwanda Cambodia 51–100 101–300 301–1000 1001–5000 >5000 Data not available Not applicable Lao PDR, Lao People’s Democratic Republic; US$: United State dollars. Adapted from World Health Organization (2014) http://gamapserver.who.int/mapLibrary/Files/Maps/PerCapitaUSD_2012.png. Success factors for reducing maternal and child mortality Policy & practice 539 Policy & practice Success factors for reducing maternal and child mortality Shyama Kuruvilla et al. review identifies cases where progress has Table 1. Necessary and sufficient conditions for fast-track progress in reducing plateaued or reversed.17 For example, in mortality rates in children under-five years of age in 144 low- and medium- Namibia, an upper-middle-income coun- income countries, 1990–2010 try, the maternal mortality ratio increased from to 271 to 449 per 100 000 live births Factors Necessity Sufficiency between 1991 and 2007. Zere et al.38 dis- Scoresa Scoresb cuss how this increase was due to unequal access to quality emergency obstetric care Ratio of young literate females to males (ages 12–24 0.929 0.289 years)c between the rural poor and the urban Immunization against measles (% children aged 12–13 0.862 0.269 wealthy. In Brazil and Peru, concerted months vaccinated) efforts to address similar sub-national in- Total fertility rate (reduction) 0.862 0.313 equalities have brought about progress.18,39 Female to male ratio in primary educationc 0.857 0.262 The Success Factors literature review discusses how countries also adapt strate- Immunization with DPT (% of children aged 12–13 0.857 0.235 months vaccinated)c gies based on changing needs and avail- Immunization against measles, lagged (% 12–13 0.857 0.245 able resources, Malaysia, Sri Lanka and month old children)c Thailand initially focused on improving Immunization for polio (% of one-year old children 0.857 0.212 primary and community-based health receiving three doses)c care in rural areas. As their health systems Access to improved water source (% of population) 0.828 0.273 became stronger, the emphasis shifted to Birth attendance by skilled health staff (%) 0.786 0.262 quality improvements and then to macro- Births attended by skilled health staff, lagged (%)c 0.786 0.262 level health reforms for universal health coverage that all contributed to improved Ethnic fractionalization (negative effect) 0.786 0.282 maternal and child health outcomes.17,40,41 Expected years of schooling (females)c 0.786 0.314 The progress that accrues over time from Expected years of schooling (males)c 0.786 0.289 strengthening systems and adaptive Pregnant women receiving antenatal care (%)c 0.786 0.212 strategies should not be undervalued by Total fertility rate (reduction)c 0.786 0.262 measuring a country’s progress only by Urban population (%) 0.786 0.239 the initial rates of decline in mortality.14,17 Urban population, lagged (%)c 0.786 0.244 Different ways of measuring a coun- Health expenditure per capita (PPP constant 2005) 0.714 0.333 try’s rates of mortality reduction result in Immunization with BCG (% of one-year old children)c 0.714 0.189 different pictures of progress, for example, Improved sanitation facilities (% population with 0.714 0.244 sub-Saharan African countries reduced access) deaths of children under five years of age Physicians (per 1000 people) 0.714 0.417 on average by 60/1000 live births between Female legislators, senior officials, managers (%) 0.586 0.459 1990 and 2012 —making it second only GDP per capita 0.586 0.347 to South Asia (74/1000) in terms of abso- Gini index (negative effect) 0.483 0.259 lute decline in mortality. However, when BCG: Bacillus Calmette–Guérin; DPT: diphtheria, pertussis and tetanus; GDP: gross domestic product; PPP: reported as the annual rate of change, it purchasing power parity. appears that the least progress has been a A necessity score of 1.0 is the highest and 0 the lowest. Several factors have a high necessity score – achieved in this region (for example, the above 0.75 – indicating that a combination of multisector factors is required for fast track progress. A Latin American/Caribbean region reduced high necessity score indicates that improving this variable is necessary for fast-track progress. It does not under-five mortality by 5%, south Asia by indicate the coverage level – or cut-off point – required for fast-track progress as this varied by country. b A sufficiency score of 1.0 is the highest and any factor with this score would effectively guarantee 3.7%, and sub-Saharan Africa by just 2%). fast-track progress. No single factor was sufficient to ensure fast track progress, again indicating that a By looking at absolute decline in mortality, combination of factors is required. we get a better idea of overall reduction in c With lagged effect of 10 years. numbers of deaths over time.14 Adapted from: Caramani D, et al. (2014).16 Guiding principles The Secretary of the Ministry of Health cies and programmes, and alignment of Fast-track countries use guiding princi- and Population affirmed that: “Many partners with country priorities. ples to chart their own pathways to prog- government strategies and policies related Principles based on different politi- ress. These principles are not a panacea, to safer motherhood, neonatal health, cal systems and models of economic and but they nevertheless shape government nutrition and gender are anchored in the social development also steer progress. strategies, align stakeholder action and principles of human rights.”18,42 China has experienced a clear evolution orient progress towards agreed results. Other fast-track countries used of different political philosophies and The principles are continually being de- guiding principles aligned with frame- systems.18,19 Currently it aims to address fined, tested and reformed. works for effective development, for the challenge of achieving harmonization Some fast-track countries explicitly example the Paris Principles and Accra and balance across five axes of national adopted human rights-based principles Agenda for Action.43 In these countries, development: rural–urban, western–east- to guide their health and development the government’s interaction with health ern regions of the country, national–in- strategies. For example, Nepal’s interim and development partners is defined by ternational, economic–social, and human constitution is founded on human rights. principles of national ownership of poli- development–natural development.18,19 540 Bull World Health Organ 2014;92:533–544| doi: http://dx.doi.org/10.2471/BLT.14.138131 Policy & practice Shyama Kuruvilla et al. Success factors for reducing maternal and child mortality further research investment, including to The country multistakeholder policy Discussion understand how nations succeed. reviews19 indicate that there is consider- The Success Factors studies used a mul- able interest in understanding and docu- Study approach and limitations tidisciplinary approach to explore why menting what works to support national some countries do better than others at The Success Factors studies used differ- planning, promote policy dialogue across preventing maternal and child mortality. ent methods which highlighted some different stakeholders and sectors, and The studies indicate that while fast-track challenges. Key strategies identified in facilitate learning across countries. Policy countries did not have a simple formula the qualitative country review data were analysis, within and beyond the health for success, progress across a core set of difficult to measure quantitatively. For sector, is an important area for further multisector factors is essential. Fast-track example, there are limited measures of research, technical assistance and policy countries maximize health outcomes us- enabling factors such as value for money collaboration. ing catalytic strategies, including through and the adaptive capacities of different Policy-makers in the fast-track leadership and partnerships across soci- countries. For other factors such as lead- countries may build on lessons learnt ety, and evidence-informed, innovative, ership, indicators and data exist, but only to address ongoing and new challenges. context-specific approaches. They also for a limited set of countries and years.49 There is the unfinished MDG agenda define and test guiding principles to shape The Success Factors studies did not around mortality reduction, particularly policies, align action and achieve results. include as factors other health-related newborn mortality and preventing still- The 10 fast-track countries improved outcomes such as the prevalence of hu- births. In addition, high-, middle- and health outcomes despite relatively low man immunodeficiency virus (HIV) or low-income countries all face challenges health expenditures and GDP per capita, nutritional status of the population and in promoting the well-being of their and in the face of considerable political thus did not ascertain the effect of these populations across the life course, ad- and socioeconomic challenges.18,19 These variables. Further, women’s and children’s dressing inequalities, managing climate findings are consistent with the “Good health extends well beyond mortality change and population dynamics, and Health at Low Cost” studies that show that reduction to addressing risk factors and balancing economic, social and sustain- health can be achieved with relatively few promoting well-being throughout the life able development. resources if these are used strategically.44 course. While recognizing this broader Aligned with the Global Investment Frame- context, reducing preventable maternal Conclusion work for Women’s and Children’s Health,5 and child mortality was the focus of the The Success Factors studies confirm, as the Success Factors analysis shows that Success Factors studies. posited by the UN Millennium Project,20 investments in packages of high-impact The quantitative analyses compared that investments across multiple sectors interventions and health systems contribute progress between fast-track LMICs and are required for countries to accelerate to better progress: for example, in immuni- other LMICs (Fig. 3, Fig. 4, Fig. 5, Fig. 6 progress towards health and development zation and other child health interventions, and Table 1). The in-depth country- goals. Importantly, this integrative, cross- skilled birth attendance and maternal and specific reviews were limited by their sectoral approach is being emphasized in newborn health care, and family planning. focus on 10 fast-track countries, without the design of the post-2015 sustainable The Success Factors studies note the a counterfactual or comparative analysis. development goals.51 Other enabling fac- importance of robust and timely evidence Examining cases with unexpectedly poor tors include good governance, evidence- to support decision-making and promote performance would be helpful for future informed, context-specific strategies, and accountability in fast-track countries. research and planning. guiding principles to orient progress. This This aligns with a previous World Bank Policy and research implications evidence synthesis contributes to a grow- analysis emphasizing that knowledge is ing field of knowledge on how to acceler- at least as important as economic capital Multisector progress is key to accelerating ate progress for women’s and children’s in improving well-being.45 positive results. Having shared goals and health towards 2015 and beyond. ■ The Success Factors studies find- investments across sectors could further ings support previous analyses showing strengthen these results, for example that building on the complementary ensuring clean water and sustainable Acknowledgements objectives and principles for develop- energy for health-care facilities, reducing We gratefully acknowledge the contri- ment effectiveness and human rights is air pollution, and promoting health and butions of all colleagues on the Success potentially beneficial for women’s and nutrition in schools. However, institu- Factors Study Groups and Country children’s health.43,46,47 There is a recog- tional barriers to meaningful multisector Multistakeholder Policy Review Groups. nized need to continually research the collaboration are formidable. Further The full list of contributors, technical definition, implementation and impact analysis is needed to identify how fast- papers and country policy reports can be of these principles on women’s and chil- track countries overcame these barriers. accessed at: http://www.who.int/pmnch/ dren’s health and for inclusive, sustain- In progressing towards MDGs 4 and knowledge/publications/successfactors able development overall.19 These find- 5, fast-track countries took into account ings are aligned with ongoing research the global development agenda and goals, Funding: Partnership for Maternal, New- on the impact of different political and but emphasized context-specific needs, born & Child Health, World Bank, World institutional models to explain why na- priorities and capacities. This suggests Health Organization and Alliance for tions fail.48 Political and policy analyses, that global goals could be usefully aug- Health Policy and Systems Research. and related implementation and impact mented and operationalized by taking assessments, are important areas for into account country-specific targets.50 Competing interests: None declared. Bull World Health Organ 2014;92:533–544| doi: http://dx.doi.org/10.2471/BLT.14.138131 541 Policy & practice Success factors for reducing maternal and child mortality Shyama Kuruvilla et al. ‫ملخص‬ ‫عوامل النجاح يف احلد من وفيات األمومة والطفولة‬ .‫املجاالت الرئيسية الثالثة بغية احلد من وفيات األمومة والطفولة‬ ‫يمثل احلد من وفيات األمومة والطفولة إحدى أولويات األهداف‬ ‫ تقوم هذه البلدان بإرشاك العديد من القطاعات يف التعاطي‬،‫ال‬ ً ‫أو‬ .2015 ‫) وحيتمل أن يظل كذلك بعد عام‬MDG( ‫اإلنامئية لأللفية‬ ‫ وقد نتج حوايل نصف‬.‫مع املحددات احلاسمة يف جمال الصحة‬ ‫وتوجد بينات حول االستثامرات والتدخالت وسياسات التمكني‬ ‫االنخفاض يف وفيات الطفولة يف البلدان املنخفضة واملتوسطة‬ ‫ وال يزال ما نفهمه عن أسباب إحراز بعض البلدان‬.‫املطلوبة‬ ‫ ويعزى‬،‫ عن االستثامرات يف قطاع الصحة‬1990 ‫الدخل منذ عام‬ ً ‫للتقدم عىل نحو أرسع من غريها من البلدان القابلة للمقارنة قلي‬ .‫ال‬ ،‫ ثاني ًا‬.‫النصف اآلخر إىل االستثامرات يف قطاعات خارج الصحة‬ ‫وقد استهدفت عوامل النجاح لدراسات صحة املرأة والطفل‬ ‫تستخدم هذه البلدان اسرتاتيجيات حلشد الرشكاء يف خمتلف‬ ‫التعاطي مع هذه الثغرة املعرفية باستخدام التحليالت اإلحصائية‬ ‫ باستخدام البينات القوية يف الوقت املناسب‬،‫قطاعات املجتمع‬ ‫ بلد ًا من البلدان‬144 ‫واالقتصادية القياسية للبيانات املستمدة من‬ ‫الختاذ القرارات واملساءلة وهنج ختطيط ثالثي لدراسة االحتياجات‬ ‫ سنة؛ وحتليل‬20 ‫) عىل مدار‬LMIC( ‫املنخفضة واملتوسطة الدخل‬ ‫ تضع‬،‫ ثالث ًا‬.‫العاجلة والرؤية طويلة األمد والتكيف مع التغري‬ ‫املقارنة النوعي املنطقي؛ واستعراض الكتابات؛ واالستعراضات‬ ‫البلدان املبادئ اإلرشادية التي توجه التقدم وتتواءم مع إجراءات‬ ‫اخلاصة بكل بلد يف البلدان العرش يف مبادرة املسار الرسيع من‬ ‫ ويسهم تركيب‬.‫أصحاب املصلحة وحتقق النتائج بمرور الوقت‬ .‫أ من األهداف اإلنامئية لأللفية‬5‫ و‬4 ‫أجل حتقيق بلوغ اهلدف‬ ‫البينات يف التعلم العاملي املعني بترسيع التحسينات يف جمال صحة‬ ‫ فبلدان مبادرة املسار الرسيع تنرش‬- ‫وال توجد صيغة موحدة‬ .‫ وما بعده‬2015 ‫املرأة والطفل صوب عام‬ ،‫ ومع ذلك‬.‫اسرتاتيجيات خمصصة وتتكيف برسعة مع التغيري‬ ‫تشارك بلدان املسار الرسيع بعض النهج الفعالة يف التعاطي مع‬ 摘要 降低孕产妇和儿童死亡率的成功因素 降低孕产妇和儿童死亡率是千年发展目标 (MDG) 的当 拥有某些相同的有效方法。首先 , 这些国家组织多个 务之急 , 在 2015 年之后可能仍是如此。证据存在于所 部门参与以应对至关重要的健康决定因素。自 1990 年 需的投资、干预和支持政策。一些国家比其他类似国 以来 ,LMIC 国家中大约一半儿童死亡率减少归因于卫 家取得更快进展的原因还有待于进一步探讨。妇女和 生部门投入 , 另一半则归因于健康以外行业的投入。 儿童健康的成功因素研究试图弥合这一知识差距 , 其 其次 , 这些国家使用策略动员全社会合作伙伴 : 使用及 中利用了对 20 多年来 144 个中低收入国家 (LMIC) 的 时、健壮的证据进行决策和问责 , 并采用三重规划方 数据进行的统计学和计量经济学分析 ; 布尔、定性比 法来考虑紧急需求、长期愿景和应变调整。第三 , 这 较分析 ; 文献综述 ; 在 10 个取得快速进展国家对 MDG 些国家建立了确定发展方向、协调利益相关者行动的 4 和 5a 实现情况的国别回顾。不存在放之四海皆准的 指导原则 , 久而久之收到成效。本次证据综合积累了 公式——高绩效国家因地制宜部署策略 , 应对变化进 促进 2015 年及以后妇女和儿童健康改善方面的全球知 行调整时行动迅速。但是在解决三个主要领域问题来 识。 降低孕产妇和儿童死亡率方面 , 走在快车道上的国家 Résumé Facteurs de réussite pour la réduction de la mortalité maternelle et infantile La réduction de la mortalité maternelle et infantile est une priorité infantile. Premièrement, ils impliquent de nombreux secteurs pour traiter des objectifs du Millénaire pour le développement (OMD) et le restera les facteurs déterminants et cruciaux pour la santé. Près de la moitié de probablement après l’échéance de 2015. Il existe des données sur la réduction de la mortalité infantile dans les pays à faible revenu et à les investissements, les interventions et les politiques habilitantes revenu intermédiaire depuis 1990 résulte des investissements dans le nécessaires. On comprend mal pourquoi certains pays ont réalisé secteur de la santé, l’autre moitié étant attribuée aux investissements des progrès plus rapidement que d’autres pays comparables. Les réalisés dans les secteurs extérieurs à la santé. Deuxièmement, ces pays Facteurs de réussite des études sur la santé des femmes et des enfants utilisent des stratégies pour mobiliser les partenaires dans la société, en ont cherché à combler ce manque de connaissances en utilisant utilisant des données solides et opportunes pour la prise de décisions et les analyses statistiques et économétriques des données provenant la responsabilisation, ainsi qu’une approche de planification triple pour de 144 pays à faible revenu et à revenu intermédiaire et recueillies prendre en considération les besoins immédiats, la vision à long terme depuis 20 ans: une analyse comparative qualitative booléenne; une et l’adaptation aux changements. Troisièmement, ces pays établissent étude bibliographique et des études spécifiques à chaque pays pour des principes directeurs qui orientent les progrès, harmonisent les les 10 pays à progression rapide pour les points 4 et 5a des OMD. Il actions des parties prenantes et génèrent des résultats dans le temps. n’existe pas de formule standard – les pays à progression rapide ont Cette synthèse de données contribue à l’ensemble des connaissances déployé des stratégies personnalisées et se sont adaptés rapidement requises pour accélérer les améliorations sur la santé des femmes et des aux changements. Cependant, ces pays ont en commun des approches enfants en vue de l’échéance de 2015 et au-delà. efficaces visant 3 grands axes afin de réduire la mortalité maternelle et 542 Bull World Health Organ 2014;92:533–544| doi: http://dx.doi.org/10.2471/BLT.14.138131 Policy & practice Shyama Kuruvilla et al. Success factors for reducing maternal and child mortality Резюме Факторы успеха для снижения материнской и детской смертности Снижение материнской и детской смертности является одним снижения материнской и детской смертности. Во-первых, эти из приоритетов Целей тысячелетия в области развития (ЦТР) и страны привлекают несколько секторов для решения проблем, останется таковым и после 2015 года. Практика показывает, что связанных с важнейшими детерминантами здоровья. Успехи, для реализации этих целей требуется дальнейшее вложение достигнутые в снижении детской смертности в СНСД с 1990 года, инвестиций, проведение мероприятий и стимулирующей примерно наполовину являются результатом инвестиций в сектор политики. До конца непонятно, почему некоторые страны здравоохранения, а другая половина связана с инвестициями в достигают прогресса в решении проблем быстрее, чем другие другие сектора помимо здравоохранения. Во-вторых, эти страны сопоставимые страны. Были проведены исследования «Факторы используют стратегии для мобилизации партнеров во всех слоях успеха для здоровья женщин и детей» для восполнения этого общества, применяя своевременные, надежные доказательства пробела в знаниях, используя следующие методы: статистический для принятия решений и подотчетности, а также тройной и эконометрический анализ данных для 144 стран с низким плановый подход, включающий в себя насущные потребности, и средним уровнем доходов (СНСД) за 20-летний период, долгосрочное видение и адаптацию к изменениям. В-третьих, эти логический, качественный и сравнительный анализы, обзор страны разрабатывают руководящие принципы, позволяющие литературы, обзоры 10 опережающих стран по показателям направлять развитие, согласовывать действия заинтересованных ЦТР 4 и 5а. Для решения этих проблем нет стандартной сторон и достигать результатов с течением времени. Достигнутые формулы — страны с опережающими показателями применяют в этих странах успехи способствуют всеобъемлющему изучению целевые стратегии и быстро адаптируются к изменениям. способов ускоренного достижения улучшений в сфере охраны Тем не менее, опережающие страны делятся некоторыми здоровья женщин и детей к 2015 году и в последующие годы. эффективными подходами в трех основных областях с целью Resumen Factores de éxito para reducir la mortalidad materna e infantil La reducción de la mortalidad materna e infantil es una prioridad en los infantil. En primer lugar, involucran a numerosos sectores para hacer Objetivos de Desarrollo del Milenio (ODM), y probablemente lo seguirá frente a los factores sanitarios decisivos. Alrededor de la mitad de la siendo después de 2015. Existen evidencias sobre las inversiones, las reducción de la mortalidad infantil en los PIBM desde 1990 es el resultado intervenciones y las políticas necesarias, pero se sabe menos acerca de inversiones en el sector de la salud, y la otra mitad se atribuye a de por qué algunos países logran un progreso más rápido que otros las inversiones realizadas en sectores fuera del ámbito sanitario. En países comparables. Los estudios relativos a los Factores de Éxito en la segundo lugar, estos países utilizan estrategias para movilizar a socios Salud de las Mujeres y los Niños han tratado de abordar esta brecha de a través de la sociedad, utilizando evidencias oportunas y sólidas para conocimiento por medio de análisis estadísticos y econométricos de la toma de decisiones y la rendición de cuentas, así como un enfoque datos de 144 países de ingresos bajos y medianos (PIBM) a lo largo de de planificación triple para considerar las necesidades inmediatas, la más de 20 años, análisis comparativos cualitativos booleanos, revisión visión a largo plazo y la adaptación al cambio. En tercer lugar, los países de la literatura y revisiones específicas de cada país en 10 países bien establecen principios rectores que orientan el progreso, armonizan las encarrilados para los ODM 4 y 5a. No existe una fórmula estándar, estos acciones de las partes interesadas y logran resultados en el tiempo. países despliegan estrategias a medida y se adaptan rápidamente a los Este compendio de evidencias contribuye al aprendizaje global sobre cambios. Sin embargo, comparten ciertos enfoques eficaces a la hora cómo acelerar las mejoras en la salud de mujeres y niños hacia el 2015 de abordar tres áreas principales para reducir la mortalidad materna e y más adelante. References 1. United Nations Secretary-General. Global strategy for women’s and children’s 6. World Health Organization, Aga Khan University, Partnership for Maternal, health. New York (NY): United Nations; 2010. Available from: http:// Newborn & Child Health and partners. Essential interventions, commodities www.everywomaneverychild.org/images/content/files/global_strategy/ and guidelines for reproductive, maternal, newborn and child health. Geneva: full/20100914_gswch_en.pdf [cited 2014 May 12]. World Health Organization; 2011. 2. UN Inter-agency Group for Child Mortality Estimation. Levels and trends in 7. World Health Organization, Partnership for Maternal, Newborn & Child health child mortality. New York (NY): United Nations Children’s Fund; 2013. Available and partners. A policy guide for implementing essential interventions for from: http://www.childinfo.org/files/Child_Mortality_Report_2013.pdf [cited reproductive, maternal, newborn and child health (RMNCH): a multisectoral 2014 May 20]. policy compendium for RMNCH. Geneva: World Health Organization; 2014. 3. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global 8. Countdown to 2015. Countdown to 2015 and beyond: fulfilling the health causes of maternal death: a WHO systematic analysis. Lancet Global Health. agenda for women and children. Geneva: World Health Organization & 2014;2(6):e323–33. doi: http://dx.doi.org/10.1016/S2214-109X(14)70227-X UNICEF; 2014. Forthcoming. 4. Trends in maternal mortality: 1990 to 2013. Estimates by WHO, UNICEF, 9. MacFarquhar N. UN poverty goals face accountability questions. The New York UNFPA, The World Bank and the United Nations Population Division. Geneva: Times. 2010 Sep 18. World Health Organization; 2014. Available from: http://apps.who.int/iris/ 10. Success Factors for Women’s and Children’s Health [Internet]. Geneva: World bitstream/10665/112682/2/9789241507226_eng.pdf?ua=1 [cited 2014 June Health Organization; 2014. Available from: http://www.who.int/pmnch/ 12]. knowledge/publications/successfactors/en/ [cited 2014 May 12]. 5. Stenberg K, Axelson H, Sheehan P, Anderson I, Gülmezoglu AM, Temmerman 11. United Nations Millennium Project. Investing in development: a practical M, et al.; Study Group for the Global Investment Framework for Women’s and plan to achieve the Millennium Development Goals. New York (NY): United Children’s Health. Advancing social and economic development by investing Nations Development Programme; 2005. in women’s and children’s health: a new Global Investment Framework. 12. Everybody’s business: strengthening health systems to improve health Lancet. 2014;383(9925):1333–54. doi: http://dx.doi.org/10.1016/S0140- outcomes. WHO’s framework for action. Geneva: World Health Organization; 6736(13)62231-X PMID: 24263249 2007. Bull World Health Organ 2014;92:533–544| doi: http://dx.doi.org/10.2471/BLT.14.138131 543 Policy & practice Success factors for reducing maternal and child mortality Shyama Kuruvilla et al. 13. Variables included in the Success Factors for Women’s and Children’s Health 31. Lawn JE, Kinney MV, Black RE, Pitt C, Cousens S, Kerber K, et al. Newborn study database [Partnership for Maternal, Newborn & Child Health Technical survival: a multi-country analysis of a decade of change. Health Policy Plan. Paper]. Geneva: World Health Organization; 2014. Available from: http://www. 2012;27 Suppl 3:iii6–28. doi: http://dx.doi.org/10.1093/heapol/czs053 PMID: who.int/pmnch/knowledge/publications/annex1.pdf?ua=1 [cited 2014 May 22692417 12]. 32. Tackling Ethiopia’s maternal deaths [Internet]. Nairobi: IRIN; 2013. Available 14. Adam T, Franz-Vasdeki J. A quantitative mapping of trends in reductions of from: http://www.irinnews.org/report/97383/analysis-tackling-ethiopia-s- maternal and child mortality in the high mortality-burden Countdown to maternal-deaths [cited 2014 May 12]. 2015 countries [Partnership for Maternal, Newborn & Child Health Technical 33. Yanqiu G, Ronsmans C, Lin A. Time trends and regional differences in Paper]. Geneva: World Health Organization; 2012. maternal mortality in China from 2000 to 2005. Bull World Health Organ. 15. Bishai D, Cohen RL, Alfonso YN, Adam T, Kuruvilla S, Schweitzer J. Factors 2009;87(12):913–20. doi: http://dx.doi.org/10.2471/BLT.08.060426 PMID: contributing to child mortality reductions in 142 low-and middle-income 20454482 countries between 1990 and 2010. In: Population Association of America, 34. Chowdhury S, Vergeer P, Schmidt H, Barroy H, Bishai D, Halpern S. Economics 2014 Annual Meeting; 2014 May 1; Boston, United States of America. Silver and ethics of results-based financing for family planning: evidence and policy Spring (MD): Population Association of America: 2014. implications. Washington (DC): World Bank; 2013. 16. Caramani D, Eugster B. Which factors are necessary and/or sufficient for 35. Khanal L, Dawson P, Silwal RC, Sharma J, Kc NP, Upreti SR. Exploration and accelerated reduction of maternal and child mortality in low and middle- innovation in addressing maternal, infant and neonatal mortality. J Nepal income countries? Results from a Boolean, Qualitative Comparative Analysis Health Res Counc. 2012;10(21):88–94. PMID: 23034368 (QCA). [Partnership for Maternal, Newborn & Child Health Technical Paper]. 36. VanRooyen MJ, Erickson TB, Jones PW, Townes DA, Jurkowski ET, Levy P. Health Geneva: World Health Organization; 2014. care in post-war Rwanda: re-establishing a national hospital using a mentor 17. Frost L, Pratt BA. Review of the literature on factors contributing to the approach. J Health Adm Educ. 1997 Spring;15(2):101–11. PMID: 10174962 reductions of maternal and child mortality in low income and middle income 37. Human resources for health program [Internet]. Kigali: Republic of Rwanda; countries: an evidence synthesis for the success factors study [Partnership for 2014. Available from: http://hrhconsortium.moh.gov.rw/about-hrh/program- Maternal, Newborn & Child Health Technical Paper]. Geneva: World Health overview [cited 2014 May 12]. Organization; 2014. Available from: http://www.who.int/pmnch/knowledge/ 38. Zere E, Tumusiime P, Walker O, Kirigia J, Mwikisa C, Mbeeli T. Inequities in publications/qualitative_evidence_synthesis.pdf?ua=1 [cited 2014 May 12]. utilization of maternal health interventions in Namibia: implications for 18. Options Consultancy Services/ Evidence for Action (E4A), Cambridge progress towards MDG 5 targets. Int J Equity Health. 2010;9(1):16. doi: http:// Economic Policy Associates (CEPA), The Partnership for Maternal Newborn dx.doi.org/10.1186/1475-9276-9-16 PMID: 20540793 & Child Health. Country-specific literature and data review for 10 fast track 39. Victora CG, Aquino EM, do Carmo Leal M, Monteiro CA, Barros FC, countries making progress towards MDGs 4 and 5 [Partnership for Maternal, Szwarcwald CL. Maternal and child health in Brazil: progress and challenges. Newborn & Child Health Technical Paper]. Geneva: World Health Organization; Lancet. 2011;377(9780):1863–76. doi: http://dx.doi.org/10.1016/S0140- 2014. Available from: http://www.who.int/pmnch/knowledge/publications/ 6736(11)60138-4 PMID: 21561656 country_data_review.pdf?ua=1 [cited 2014 May 12]. 40. Pathmanathan I, Liljestrand J. Investing in maternal health: learning from 19. Success Factors for Women’s and Children’s Health: country multistakeholder Malaysia and Sri Lanka. Washington (DC): World Bank; 2003. p. 182. policy reviews [Internet]. Geneva: World Health Organization; 2014. Available 41. Vapattanawong P, Hogan MC, Hanvoravongchai P, Gakidou E, Vos T, Lopez from: http://www.who.int/pmnch/knowledge/publications/successfactors/ AD, et al. Reductions in child mortality levels and inequalities in Thailand: en/index2.html [cited 2014 May 12]. analysis of two censuses. Lancet. 2007;369(9564):850–5. doi: http://dx.doi. 20. Goldkuhl G, Cronholm S. Adding theoretical grounding to grounded theory: org/10.1016/S0140-6736(07)60413-9 PMID: 17350454 toward multi-grounded theory. Int J Qual Methods. 2010;9(2):187–205. 42. Patel A, Sharma S, Prost A, Sander G, Hunt P, editors. Maternal and child health 21. Mays N, Pope C, Popay J. Systematically reviewing qualitative and in Nepal. Geneva: World Health Organization; 2013. quantitative evidence to inform management and policy-making in the 43. Integrating human rights into development: donor approaches, experiences health field. J Health Serv Res Policy. 2005;10 Suppl 1:6–20. doi: http://dx.doi. and challenges. 2nd ed. Washington (DC): World Bank and Organisation for org/10.1258/1355819054308576 PMID: 16053580 Economic Co-operation and Development; 2013. 22. Glaser BG, Strauss AL. The discovery of grounded theory. Chicago (IL): Aldine; 44. Balabanova D, Mills A, Conteh L, Akkazieva B, Banteyerga H, Dash U, et 1967. al. Good Health at Low Cost 25 years on: lessons for the future of health 23. The Worldwide Governance Indicators (WGI) project [Internet]. Washington systems strengthening. Lancet. 2013;381(9883):2118–33. doi: http://dx.doi. (DC): World Bank; 2014. Available from: http://info.worldbank.org/ org/10.1016/S0140-6736(12)62000-5 PMID: 23574803 governance/wgi/index.aspx [cited 2014 May 12]. 45. World development report 1998–1999. Washington (DC): World Bank; 1999. 24. Shaping our development: economic development and poverty reduction 46. Kuruvilla S, Bustreo F, Hunt P, Singh A, Friedman E, Luchesi T, et al.; and strategy 2013–2018. Kigali: Republic of Rwanda; 2013. Available from: http:// other members of the Working Group on the MDGs and Human Rights www.minecofin.gov.rw/fileadmin/General/EDPRS_2/EDPRS_2_FINAL1.pdf for the UN Secretary-General’s Global Strategy for Women’s and Children’s [cited 2014 May 12]. Health. The Millennium Development Goals and human rights: realizing 25. Lao People’s Democratic Republic fact sheet. New York (NY): UN Women; shared commitments. Hum Rights Q. 2012;34(1):141–77. doi: http://dx.doi. 2013. Available from: http://www.unwomen-eseasia.org/docs/factsheets/04 org/10.1353/hrq.2012.0010 Lao PDR factsheet.pdf [cited 2014 May 12]. 47. Bustreo F, Hunt P, Gruskin S, Eide A, McGoey L, Rao S, et al. Women’s and 26. Bangladesh Demographic and Health Survey 2011. Dhaka and Calverton children’s health: evidence of impact of human rights. Geneva: World Health (MD): National Institute of Population Research and Training, Mitra and Organization; 2013. Associates, ICF International; 2013. 48. Acemoglu D, Robinson JA. Why nations fail: the origins of power, prosperity 27. El Arifeen S, Christou A, Reichenbach L, Osman FA, Azad K, Islam KS, et al. and poverty. New York (NY): Crown Publishers; 2012. Community-based approaches and partnerships: innovations in health- 49. House RJ, Hanges PJ, Javidan M, Dorfman PW, Gupta V. Culture, leadership, service delivery in Bangladesh. Lancet. 2013;382(9909):2012–26. doi: http:// and organizations: The GLOBE study of 62 societies. Thousand Oakes (CS): dx.doi.org/10.1016/S0140-6736(13)62149-2 PMID: 24268607 SAGE Publications Inc.; 2004. 28. Suarez R. In Peru, life for the life-givers. PBS Newshour. 2010 Mar 29. Available 50. Cohen R, Alfonso YN, Kuruvilla S, Scweitzer J, Bishai D. Post-2015 health from: http://www.pbs.org/newshour/rundown/in-peru-life-for-the-life- targets: could country-specific targets supplement global ones? Lancet givers/ [cited 2014 May 12]. Global Health. Forthcoming. 29. Koam T. Changing Cambodia one message at a time. The Phnom Penh 51. United Nations Sustainable Development Knowledge Platform. Post-2015 Post. 2010 Aug 25. Available from: http://www.phnompenhpost.com/lift/ process. New York (NY): United Nations; 2014. Available from: http:// changing-cambodia-one-message-time [cited 2014 May 23]. sustainabledevelopment.un.org/index.php?menu=1561 [cited 2014 May 12]. 30. Ethiopia community-based nutrition program helps reduce child malnutrition [Internet]. Washington (DC): World Bank; 2012. Available from: http://www. worldbank.org/en/news/feature/2012/10/16/ethiopia-community-based- nutrition-program-helps-reduce-child-malnutrition [cited 2014 May 12]. 544 Bull World Health Organ 2014;92:533–544| doi: http://dx.doi.org/10.2471/BLT.14.138131 Policy & practice Shyama Kuruvilla et al. Success factors for reducing maternal and child mortality Fig. 5. Multisector factors in African countries with the fastest and slowest rates of maternal and child mortality reduction, 1990–2010 1.3 GDP PPP, per capita % growth 1.5 1.0 Poverty < US$ 2 –12.2 per day, % –7.9 –12.6 1.7 Government effectiveness index (x10) –1.5 –2.5 12.3 Skilled birth attendance, % 9.0 5.1 0.1 Doctors per 100 people* –0.8 0.2 22.6 Measles immunization, % 15.1 6.1 9.5 Prenatal care, % 9.7 4.5 0.2 HIV prevalence, %** 4.2 8.3 5.7 Health expenditure per capita, % annual growth 6.7 4.4 –6.8 Out-of-pocket health spending, % –5.2 –1.2 12.5 Sanitation, % access* 6.6 7.5 19.5 Clean water, % access 12.9 12.0 –1.6 Total fertility rate* –1.2 –1.2 12.8 Contraceptive prevalence, % 8.4 11.3 12.7 Parliament, % women 9.2 7.6 5.8 Female labour force, % participation 3.2 4.0 1.7 Total years schooling, female 1.7 1.8 1.7 Total years schooling, both sexes 1.6 1.7 0.0 Power consumption per capita, MWh 0.1 0.2 –2.7 Roads paved, % 4.9 1.6 0.0 Published scientific papers annually, 1000s 0.1 0.0 –15.0 –10.0 –5.0 0.0 5.0 10.0 15.0 20.0 25.0 Unweighted means of absolute change between 1990 and 2010 10 African countries with the fastest rates of both U5MR and MMR reduction Other African countries (38 countries) 10 African countries with the slowest rates of both U5MR and MMR reduction * P < 0.05; ** P < 0.01; GDP: gross domestic product; HIV: human immunodeficiency virus; MMR: measles, mumps and rubella; MWh: Mega Watt hour; PPP: purchasing power parity; U5MR: under-five years mortality rate; US$: United States dollars. Note: P-values estimated using N-way ANOVA. Some values are scaled by factor of 10 to be comparable on a single chart. Bull World Health Organ 2014;92:533–544| doi: http://dx.doi.org/10.2471/BLT.14.138131 544A Policy & practice Success factors for reducing maternal and child mortality Shyama Kuruvilla et al. Fig. 6. Progress across 10 fast-track countries and 10 comparison countries, 1990–2010 GDP PPP, per capita % growth 4.1 2.3 Poverty –22.9 < US$ 2 per day, % –14.0 1.5 Government effectiveness index (x10) 0.2 Skilled birth attendance, % 22.1 19.7 3.1 Doctors per 100 people 2.5 24.0 Measles immunization, % 16.5 Prenatal care, % 2.5 18.8 HIV prevalence, % –0.1 –0.5 Health expenditure per capita, % annual growth 8.9 8.7 –3.7 Out-of-pocket health spending, % 1.5 Sanitation, % access** 26.8 14.1 Clean water, % access 20.6 16.3 Total fertility rate –2.1 –1.6 Contraceptive prevalence, % 17.7 16.4 Parliament, % women 17.8 12.4 1.4 Female labour force, % participation 2.5 Total years schooling, female 2.3 1.8 Total years schooling, both sexes 2.0 1.7 Power consumption per capita, MWh 0.7 0.3 Roads paved, % 7.1 0.6 Published scientific papers annually, 1000s 6.9 1.2 –30.0 –20.0 –10.0 0.0 10.0 20.0 30.0 Unweighted means of absolute change between 1990 and 2010 Fast-track country: Bangladesh, Cambodia, China, Egypt, Ethiopia, Lao People’s Democratic Republic, Nepal, Peru, Rwanda and Viet Nam Comparison country: Bhutan, Burundi, Ecuador, India, Mongolia, Morocco, Myanmar, Pakistan, Philippines and Uganda * P < 0.01; GDP: gross domestic product; HIV: human immunodeficiency virus; MWh: Mega Watt hour; PPP: purchasing power parity; US$: United States dollars. Note: P-values estimated using N-way ANOVA. Some values are scaled by factor of 10 to be comparable on a single chart. For each Success Factor fast-track country, one matched control country was identified to form a comparison group. These controls were selected based on similarities in 1990 by geographical region, under-five years mortality rate, U5MR, maternal mortality rate, GDP gross domestic product per capita, and population. These control countries have the added benefit of being in different geographical regions and not being affected by high rates of HIV infections, as were the “slow-track” countries in Fig. 3, Fig. 4 and Fig. 5 that were all African countries. 544B Bull World Health Organ 2014;92:533–544| doi: http://dx.doi.org/10.2471/BLT.14.138131