Joint distribution of child mortality and wealth across 30 sub-Saharan African countries over 2000-2019

Background

While reductions in child mortality have been observed across sub-Saharan African countries in the last 30 years, narrowing the gaps in under-five mortality across socioeconomic groups also requires an understanding of the multiple associations between health and welfare and socioeconomic drivers. We examined the probability density distributions in under-five mortality within countries and joint pathways of under-five mortality and wealth over time.

Methods

We used 69 Demographic and Health Surveys and 19 Malaria Indicator Surveys from 30 sub-Saharan African countries, with each country having at least two surveys conducted since 2000. We constructed a cross-country wealth index and estimated under-five death prevalence. We examined the pure distribution in under-five mortality prevalence and the joint probability distribution of wealth and under-five mortality prevalence over time, including the area of confidence ellipse which spanned the two dimensions of mortality and wealth and covered 75% of the mass of the joint distribution.

Results

Most countries experienced decreases in under-five mortality along with increases in wealth over time. However, we observed great variations in the evolution of the joint distributions across countries over time. For instance, the areas of confidence ellipse ranged from 0.178 in Ethiopia (2000) to 1.119 in Angola (2006). The change (over time) in the area of confidence ellipses ranged from 0.010 in Tanzania to 0.844 in Angola between the 2000s and 2010s. The ranking of country performance on under-five mortality varied greatly, depending on whether performance summary indicators were based on disaggregation by wealth or on full non-disaggregated distributions.

Conclusions

Our analysis points to the relevance of full distributions of health and joint distributions of health and wealth as complementary indicators of distributions of health across socioeconomic status, in assessing country performance on health.

Global trends in incidence and death of neonatal disorders and its specific causes in 204 countries/territories during 1990–2019

Background

Neonatal disorders (ND) are a significant global health issue. This article aimed to track the global trends of neonatal disorders in 204 countries/territories from 1990 to 2019.

Methods

Data was explored from the Global Burden of Disease study 2019. Estimated annual percentage change (EAPC) and age-standardized rate (ASR) were calculated to quantify the trends of neonatal disorders and their specific causes, mainly included neonatal preterm birth (NPB), neonatal encephalopathy due to birth asphyxia and trauma (NE), neonatal sepsis and other neonatal infections (NS), and hemolytic disease and other neonatal jaundice (HD).

Results

In 2019, there were 23,532.23 × 10³ incident cases of ND, and caused 1882.44 × 10³ death worldwide. During 1990–2019, trends in the overall age-standardized incidence rate (ASIR) of ND was relatively stable, but that of age-standardized death rate (ASDR) declined (EAPC = -1.51, 95% confidence interval [CI]: -1.66 to -1.36). Meanwhile, decreasing trends of ASDR were observed in most regions and countries, particularly Cook Islands and Estonia, in which the respective EAPCs were -9.04 (95%CI: -9.69 to -8.38) and -8.12 (95%CI: -8.46 to -7.77). Among the specific four causes, only the NPB showed decreasing trends in the ASIR globally (EAPC = -0.19, 95%CI: -0.26 to -0.11). Decreasing trends of ASDR caused by ND underlying specific causes were observed in most regions, particularly the HD in Armenia, with the EAPC was -13.08 (95%CI: -14.04 to -12.11).

Conclusions

Decreasing trends of death caused by neonatal disorders were observed worldwide from 1990 to 2019. However, the burden of neonatal disorders is still a considerable challenge, especially in low-resource settings, which need more effective health strategies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12765-1.

Characterising the scale-up and performance of antiretroviral therapy programmes in sub-Saharan Africa: an observational study using growth curves

OBJECTIVES

The rate of change in key health indicators (eg, intervention coverage) is an understudied area of health system performance. Rates of change in health services indicators can augment traditional measures that solely involve the absolute level of performance in those indicators. Growth curves are a class of mathematical models that can parameterise dynamic phenomena and estimate rates of change summarising these phenomena; however, they are not commonly used in global health. We sought to characterise the changes over time in antiretroviral therapy (ART) coverage in sub-Saharan Africa using growth curve models.

DESIGN

This was a retrospective observational study. We used publicly available data on ART coverage levels from 2000 to 2017 in 42 sub-Saharan African countries. We developed two ordinary differential equations models, the Gompertz and logistic growth models, that allowed for the estimation of summary parameters related to scale-up and rates of change in ART coverage. We fitted non-linear regressions for the two models, assessed goodness of fit using the Bayesian information criterion (BIC), and ranked countries based on their estimated performance drawn from the fitted model parameters.

RESULTS

We extracted country performance in rates of scale-up of ART coverage, which ranged from ≤2.5 percentage points per year (South Sudan, Sudan, and Madagascar) to ≥8.0 percentage points per year (Benin, Zimbabwe and Namibia), using the Gompertz model. Based on BIC, the Gompertz model provided a better fit than the logistic growth model for most countries studied.

CONCLUSIONS

Growth curve models can provide benchmarks to assess country performance in ART coverage evolution. They could be a useful approach that yields summary metrics for synthesising country performance in scaling up key health services.

Trends In State-Level Child Mortality, Maternal Mortality, And Fertility Rates In India

Trends in child mortality, maternal mortality, and fertility in India reveal wide variation across states. As a whole, India performs worse than many other low- and middle-income countries, although its rates of improvement have recently increased. Differences in health systems and adopted policies may account for some of the variation across Indian states.

Building the foundations for sustainable development: a case for global investment in the capabilities of adolescents

Investment in the capabilities of the world's 1·2 billion adolescents is vital to the UN's Sustainable Development Agenda. We examined investments in countries of low income, lower-middle income, and upper-middle income covering the majority of these adolescents globally to derive estimates of investment returns given existing knowledge. The costs and effects of the interventions were estimated by adapting existing models and by extending methods to create new modelling tools. Benefits were valued in terms of increased gross domestic product and averted social costs. The initial analysis showed high returns for the modelled interventions, with substantial variation between countries and with returns generally higher in low-income countries than in countries of lower-middle and upper-middle income. For interventions targeting physical, mental, and sexual health (including a human papilloma virus programme), an investment of US$4·6 per capita each year from 2015 to 2030 had an unweighted mean benefit to cost ratio (BCR) of more than 10·0, whereas, for interventions targeting road traffic injuries, a BCR of 5·9 (95% CI 5·8-6·0) was achieved on investment of $0·6 per capita each year. Interventions to reduce child marriage ($3·8 per capita each year) had a mean BCR of 5·7 (95% CI 5·3-6·1), with the effect high in low-income countries. Investment to increase the extent and quality of secondary schooling is vital but will be more expensive than other interventions-investment of $22·6 per capita each year from 2015 to 2030 generated a mean BCR of 11·8 (95% CI 11·6-12·0). Investments in health and education will not only transform the lives of adolescents in resource-poor settings, but will also generate high economic and social returns. These returns were robust to substantial variation in assumptions. Although the knowledge base on the impacts of interventions is limited in many areas, and a major research effort is needed to build a more complete investment framework, these analyses suggest that comprehensive investments in adolescent health and wellbeing should be given high priority in national and international policy.

Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015

BACKGROUND

Established in 2000, Millennium Development Goal 4 (MDG4) catalysed extraordinary political, financial, and social commitments to reduce under-5 mortality by two-thirds between 1990 and 2015. At the country level, the pace of progress in improving child survival has varied markedly, highlighting a crucial need to further examine potential drivers of accelerated or slowed decreases in child mortality. The Global Burden of Disease 2015 Study (GBD 2015) provides an analytical framework to comprehensively assess these trends for under-5 mortality, age-specific and cause-specific mortality among children under 5 years, and stillbirths by geography over time.

METHODS

Drawing from analytical approaches developed and refined in previous iterations of the GBD study, we generated updated estimates of child mortality by age group (neonatal, post-neonatal, ages 1-4 years, and under 5) for 195 countries and territories and selected subnational geographies, from 1980-2015. We also estimated numbers and rates of stillbirths for these geographies and years. Gaussian process regression with data source adjustments for sampling and non-sampling bias was applied to synthesise input data for under-5 mortality for each geography. Age-specific mortality estimates were generated through a two-stage age-sex splitting process, and stillbirth estimates were produced with a mixed-effects model, which accounted for variable stillbirth definitions and data source-specific biases. For GBD 2015, we did a series of novel analyses to systematically quantify the drivers of trends in child mortality across geographies. First, we assessed observed and expected levels and annualised rates of decrease for under-5 mortality and stillbirths as they related to the Soci-demographic Index (SDI). Second, we examined the ratio of recorded and expected levels of child mortality, on the basis of SDI, across geographies, as well as differences in recorded and expected annualised rates of change for under-5 mortality. Third, we analysed levels and cause compositions of under-5 mortality, across time and geographies, as they related to rising SDI. Finally, we decomposed the changes in under-5 mortality to changes in SDI at the global level, as well as changes in leading causes of under-5 deaths for countries and territories. We documented each step of the GBD 2015 child mortality estimation process, as well as data sources, in accordance with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).

FINDINGS

Globally, 5·8 million (95% uncertainty interval [UI] 5·7-6·0) children younger than 5 years died in 2015, representing a 52·0% (95% UI 50·7-53·3) decrease in the number of under-5 deaths since 1990. Neonatal deaths and stillbirths fell at a slower pace since 1990, decreasing by 42·4% (41·3-43·6) to 2·6 million (2·6-2·7) neonatal deaths and 47·0% (35·1-57·0) to 2·1 million (1·8-2·5) stillbirths in 2015. Between 1990 and 2015, global under-5 mortality decreased at an annualised rate of decrease of 3·0% (2·6-3·3), falling short of the 4·4% annualised rate of decrease required to achieve MDG4. During this time, 58 countries met or exceeded the pace of progress required to meet MDG4. Between 2000, the year MDG4 was formally enacted, and 2015, 28 additional countries that did not achieve the 4·4% rate of decrease from 1990 met the MDG4 pace of decrease. However, absolute levels of under-5 mortality remained high in many countries, with 11 countries still recording rates exceeding 100 per 1000 livebirths in 2015. Marked decreases in under-5 deaths due to a number of communicable diseases, including lower respiratory infections, diarrhoeal diseases, measles, and malaria, accounted for much of the progress in lowering overall under-5 mortality in low-income countries. Compared with gains achieved for infectious diseases and nutritional deficiencies, the persisting toll of neonatal conditions and congenital anomalies on child survival became evident, especially in low-income and low-middle-income countries. We found sizeable heterogeneities in comparing observed and expected rates of under-5 mortality, as well as differences in observed and expected rates of change for under-5 mortality. At the global level, we recorded a divergence in observed and expected levels of under-5 mortality starting in 2000, with the observed trend falling much faster than what was expected based on SDI through 2015. Between 2000 and 2015, the world recorded 10·3 million fewer under-5 deaths than expected on the basis of improving SDI alone.

INTERPRETATION

Gains in child survival have been large, widespread, and in many places in the world, faster than what was anticipated based on improving levels of development. Yet some countries, particularly in sub-Saharan Africa, still had high rates of under-5 mortality in 2015. Unless these countries are able to accelerate reductions in child deaths at an extraordinary pace, their achievement of proposed SDG targets is unlikely. Improving the evidence base on drivers that might hasten the pace of progress for child survival, ranging from cost-effective intervention packages to innovative financing mechanisms, is vital to charting the pathways for ultimately ending preventable child deaths by 2030.

FUNDING

Bill & Melinda Gates Foundation.

Disparities in Under-Five Child Injury Mortality between Developing and Developed Countries: 1990-2013

OBJECTIVE

Using estimates from the 2013 Global Burden of Disease (GBD) study, we update evidence on disparities in under-five child injury mortality between developing and developed countries from 1990 to 2013.

METHODS

Mortality rates were accessed through the online visualization tool by the GBD study 2013 group. We calculated percent change in child injury mortality rates between 1990 and 2013. Data analysis was conducted separately for <1 year and 1-4 years to specify age differences in rate changes.

RESULTS

Between 1990 and 2013, over 3-fold mortality gaps were observed between developing countries and developed countries for both age groups in the study time period. Similar decreases in injury rates were observed for developed and developing countries (<1 year: -50% vs. -50% respectively; 1-4 years: -56% vs. -58%). Differences in injury mortality changes during 1990-2013 between developing and developed nations varied with injury cause. There were greater reductions in mortality from transport injury, falls, poisoning, adverse effects of medical treatment, exposure to forces of nature, and collective violence and legal intervention in developed countries, whereas there were larger decreases in mortality from drowning, exposure to mechanical forces, and animal contact in developing countries. Country-specific analysis showed large variations across countries for both injury mortality and changes in injury mortality between 1990 and 2013.

CONCLUSIONS

Sustained higher child injury mortality during 1990-2013 for developing countries merits the attention of the global injury prevention community. Countries that have high injury mortality can benefit from the success of other countries.

Factors Contributing to Maternal and Child Mortality Reductions in 146 Low- and Middle-Income Countries between 1990 and 2010

Introduction

From 1990–2010, worldwide child mortality declined by 43%, and maternal mortality declined by 40%. This paper compares two sources of progress: improvements in societal coverage of health determinants versus improvements in the impact of health determinants as a result of technical change.

Methods

This paper decomposes the progress made by 146 low- and middle-income countries (LMICs) in lowering childhood and maternal mortality into one component due to better health determinants like literacy, income, and health coverage and a second component due to changes in the impact of these health determinants. Health determinants were selected from eight distinct health-impacting sectors. Health determinants were selected from eight distinct health-impacting sectors. Regression models are used to estimate impact size in 1990 and again in 2010. Changes in the levels of health determinants were measured using secondary data.

Findings

The model shows that respectively 100% and 89% of the reductions in maternal and child mortality since 1990 were due to improvements in nationwide coverage of health determinants. The relative share of overall improvement attributable to any single determinant varies by country and by model specification. However, in aggregate, approximately 50% of the mortality reductions were due to improvements in the health sector, and the other 50% of the mortality reductions were due to gains outside the health sector.

Conclusions

Overall, countries improved maternal and child health (MCH) from 1990 to 2010 mainly through improvements in the societal coverage of a broad array of health system, social, economic and environmental determinants of child health. These findings vindicate efforts by the global community to obtain such improvements, and align with the post-2015 development agenda that builds on the lessons from the MDGs and highlights the importance of promoting health and sustainable development in a more integrated manner across sectors.

Are global and regional improvements in life expectancy and in child, adult and senior survival slowing?

Improvements in life expectancy have been considerable over the past hundred years. Forecasters have taken to applying historical trends under an assumption of continuing improvements in life expectancy in the future. A linear mixed effects model was used to estimate the trends in global and regional rates of improvements in life expectancy, child, adult, and senior survival, in 166 countries between 1950 and 2010. Global improvements in life expectancy, including both child and adult survival rates, decelerated significantly over the study period. Overall life expectancy gains were estimated to have declined from 5.9 to 4.0 months per year for a mean deceleration of -0.07 months/year²; annual child survival gains declined from 4.4 to 1.6 deaths averted per 1000 for a mean deceleration of -0.06 deaths/1000/year²; adult survival gains were estimated to decline from 4.8 to 3.7 deaths averted per 1000 per year for a mean deceleration of -0.08 deaths/1000/year². Senior survival gains however increased from 2.4 to 4.2 deaths averted per 1000 per year for an acceleration of 0.03 deaths/1000/year². Regional variation in the four measures was substantial. The rates of global improvements in life expectancy, child survival, and adult survival have declined since 1950 despite an increase in the rate of improvements among seniors. We postulate that low-cost innovation, related to the last half-century progress in health–primarily devoted to children and middle age, is reaping diminishing returns on its investments. Trends are uneven across regions and measures, which may be due in part to the state of epidemiological transition between countries and regions and disparities in the diffusion of innovation, accessible only in high-income countries where life expectancy is already highest.

Improving life expectancy: how many years behind has the USA fallen? A cross-national comparison among high-income countries from 1958 to 2007

OBJECTIVE

Many studies have documented higher mortality levels in the USA compared to other high-income nations. We add to this discussion by quantifying how many years behind comparison countries the USA has fallen and by identifying when US mortality rates began to diverge.

DESIGN

We use full life tables, for men and women, for 17 high-income countries including the USA. We extract the life expectancy at birth and compute the mortality rates for each 5-year age group from birth up to age 80. Using the metric of how many 'years behind' a country has fallen, we compare US mortality levels with those in other high-income countries ('comparators').

RESULTS

We report life expectancy for 17 high-income countries, for the period 1958-2007. Up to the late 1970s, US men and especially women closely tracked comparators in life expectancy. In the late 1970s in the USA, most strikingly women began to diverge from comparators so that the US female life expectancy in 2007 corresponded to that of the comparators' average 10 years earlier. Mortality rates also began to diverge from the late 1970s, and the largest mortality gap was in the 15-49 age group, for both men and women, where the USA had fallen about 40 years behind the comparators by 2007.

CONCLUSIONS

Some causes proposed for the relatively high US mortality today-racial differences, lack of universal health insurance, US exceptionalism-changed little while the mortality gap emerged and grew. This suggests that explanations for the growing gap lie elsewhere. Quantification of how many years behind the USA has fallen can help provide clues about where to look for potential causes and remedies.