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Background 3 years before the 2015 deadline, Ethiopia achieved Millennium Development Goal 4. The under-5 mortality decreased 69%, from 205 deaths per 1000 livebirths in 1990 to 64 deaths per 1000 livebirths in 2013. To understand the underlying factors that contributed to the success in achieving MDG4, Ethiopia was selected as a Countdown to 2015 case study. Methods We used a set of complementary methods to analyse progress in child health in Ethiopia between 1990 and 2014. We used Demographic Health Surveys to analyse trends in coverage and equity of key reproductive, maternal health, and child health indicators. Standardised tools developed by the Countdown Health Systems and Policies working group were used to understand the timing and content of health and non-health policies. We assessed longitudinal trends in health-system investment through a financial analysis of National Health Accounts, and we used the Lives Saved Tool (LiST) to assess the contribution of interventions towards reducing under-5 mortality. Findings The annual rate of reduction in under-5 mortality increased from 3·3% in 1990–2005 to 7·8% in 2005–13. The prevalence of stunting decreased from 60% in 2000 to 40% in 2014. Overall levels of coverage of reproductive, maternal health, and child health indicators remained low, with disparities between the lowest and highest wealth quintiles despite improvement in coverage for essential health interventions. Coverage of child immunisation increased the most (21% of children in 2000 vs 80% of children in 2014), followed by coverage of satisfied demand for family planning by women of reproductive age (19% vs 63%). Provision of antenatal care increased from 10% of women in 2000 to 32% of women in 2014, but only 15% of women delivered with a skilled birth attendant by 2014. A large upturn occurred after 2005, bolstered by a rapid increase in health funding that facilitated the accelerated expansion of health infrastructure and workforce through an innovative community-based delivery system. The LiST model could explain almost 50% of the observed reduction in child mortality between 2000 and 2011; and changes in nutritional status were responsible for about 50% of the 469 000 lives saved between 2000 and 2011. These developments occurred within a multisectoral policy platform, integrating child survival and stunting goals within macro-level policies and programmes for reducing poverty and improving agricultural productivity, food security, water supply, and sanitation. Interpretation The reduction of under-5 mortality in Ethiopia was the result of combined activities in health, nutrition, and non-health sectors. However, Ethiopia still has high neonatal and maternal morbidity and mortality from preventable causes and an unfinished agenda in reducing inequalities, improving coverage of effective interventions, and strengthening multisectoral partnerships for further progress. Funding Bill & Melinda Gates Foundation and Government of Canada.
We adapted a standard evaluation framework used to guide all Countdown case studies.1 The framework depicts the pathways through which the health system, health and non-health determinants, programmes and strategies, and contextual factors affect child survival.10 We used a set of complementary methods and a variety of nationally representative data sources, and we reviewed documents, reports, and articles. The analyses were based on structured tools emerging from the Countdown to 2015’s four technical working groups: Health Systems and Policies, Health Financing, Coverage, and Equity plus the LiST modelling process. We used three standardised tools developed by the Countdown Health Systems and Policies working group: (1) the Policy and Programme Timeline Tool; (2) the Health Policy Tracer Indicators Dashboard; and (3) the Health Systems Tracer Indicators Dashboard.10, 11 Data were derived from scientific and grey literature published between 1990 and 2014, which included peer-reviewed reports and health policy strategy documents from the Ethiopian Ministry of Health, WHO, UN agencies, and UN databases.10 We supplemented our findings with interviews of 68 key stakeholders from regional government health offices, two federal administrative cities, and non-governmental organisations. Five rounds of National Health Accounts, including child health subaccounts, were compiled using a health-financing guide.12 We analysed longitudinal trends in health financing from total health expenditures in 1996–2011 and from child health expenditures in 2005–11. We reviewed public expenditure reviews and Ethiopian Government documents covering financing, economic development, and health, including the Health Care and Financing Strategy. All expenditure data were converted to constant US$ with the base year of 2012, using the official 1996–2011 consumer price index for Ethiopia. We analysed trends in reproductive, maternal, newborn, and child health (RMNCH) coverage indicators (a co-coverage index) and equity measures across wealth quintiles, regions, and residential groups using Stata 14. We used the Ethiopian Demographic and Health Surveys (DHS) from 2000,5 2005,6 and 20117 to calculate coverage indicators and confidence intervals. Published results of the 2014 mini-DHS presented further trends in coverage.13 We used the standard DHS wealth index derived from a principal component analysis divided into five quintiles.14, 15 Classification of residences as urban or rural was based on boundaries defined by national authorities. We used LiST (version 5.06) to estimate additional child deaths (including neonatal deaths) prevented by scale-up of health interventions, as reflected in the under-5 mortality data from 2000–11. LiST uses demographic information to model changes in child mortality from specific causes of death and changes in coverage of interventions or nutritional status.16 Causes of death were derived from WHO estimates,17 whereas mortality data were from the UN Inter-agency Working Group for Child Mortality Estimation.4, 18 All available coverage indicators were recalculated using standard Countdown definitions or LiST definitions. The default UN 2012 population data were adjusted in 2000 for child mortality estimates based on the Ethiopian Central Statistical Agency demographic projection of 1994.19 We used datasets from nationally representative household surveys, including the DHS, Ethiopia National Malaria Indicator Surveys (from 2007 and 2012), National Nutrition Programme Baseline Survey (2009), National Immunization Coverage Survey (2012), and Performance Monitoring and Accountability 2020. We used the reported number of beneficiaries in the Productive Safety Net Programme assessment to recalculate the balanced energy supplementation of pregnant women, and the 2008 National Baseline Assessment for Emergency Obstetric Care report to estimate service coverage at hospitals and health centres. The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.
