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Summary
Lancet 2008; 371: 1276–83 Background A recent national survey in Tanzania reported that mortality in children younger than 5 years dropped
Ifakara Health Research and by 24% over the 5 years between 2000 and 2004. We aimed to investigate yearly changes to identify what might have
Development Centre, Ifakara, contributed to this reduction and to investigate the prospects for meeting the Millennium Development Goal for child
Tanzania (H Masanja PhD,
survival (MDG 4).
Prof D de Savigny PhD,
P Smithson MPH,
J Schellenberg PhD, Methods We analysed data from the four demographic and health surveys done in Tanzania since 1990 to generate
H Mshinda PhD); Swiss Tropical estimates of mortality in children younger than 5 years for every 1-year period before each survey back to 1990. We
Institute, Basel, Switzerland
estimated trends in mortality between 1990 and 2004 by fitting Lowess regression, and forecasted trends in mortality
(D de Savigny, Prof T Smith PhD);
London School of Hygiene and in 2005 to 2015. We aimed to investigate contextual factors, whether part of Tanzania’s health system or not, that
Tropical Medicine, London, UK could have affected child mortality.
(J Schellenberg); World Health
Organization, Dar es Salaam,
Tanzania (T John MSc); Ministry
Findings Disaggregated estimates of mortality showed a sharp acceleration in the reduction in mortality in children
of Health and Social Welfare, younger than 5 years in Tanzania between 2000 and 2004. In 1990, the point estimate of mortality was 141·5 (95% CI
Dar es Salaam, Tanzania 141·5–141·5) deaths per 1000 livebirths. This was reduced by 40%, to reach a point estimate of 83·2 (95% CI
(C Mbuya MPH, G Upunda MPH); 70·1–96·3) deaths per 1000 livebirths in 2004. The change in absolute risk was 58·4 (95% CI 32·7–83·8; p<0·0001).
World Health Organization,
Geneva, Switzerland
Between 1999 and 2004 we noted important improvements in Tanzania’s health system, including doubled public
(T Boerma PhD); and University expenditure on health; decentralisation and sector-wide basket funding; and increased coverage of key child-survival
of Pelotas, Pelotas, Brazil interventions, such as integrated management of childhood illness, insecticide-treated nets, vitamin A supplementation,
(Prof C Victora PhD) immunisation, and exclusive breastfeeding. Other determinants of child survival that are not related to the health
Correspondence to: system did not change between 1999 and 2004, except for a slow increase in the HIV/AIDS burden.
Honorati Masanja, Ifakara Health
Research and Development
Centre, Kiko Avenue, Plot N 463, Interpretation Tanzania could attain MDG 4 if this trend of improved child survival were to be sustained. Investment
Mikocheni, Dar es Salaam, in health systems and scaling up interventions can produce rapid gains in child survival.
Tanzania
hmasanja@ihrdc.or.tz
Funding Government of Norway.
younger than 5 years, to 112 deaths per 1000, was reproductive and child health, that used a smaller sample size but identical methods for estimation of mortality.
calculated from the average mortality across the 5 years Table 1: Estimates of mortality in children younger than 5 years
before the survey.
Such a decline is unlikely to be due to one factor.17 But in 1991–92, and 22 000 in 2001–02. The sampling of the
what can account for it? What are the prospects now for survey was designed to allow estimates of household
Tanzania to reach MDG 4 over the ensuing 10 years? And variables for the 21 administrative regions of mainland
what can we learn that would help other countries to Tanzania. Household and individual indicators included
accelerate progress towards MDG 4? We aimed to measures of income poverty and performance of priority
calculate the annual rates to examine the pattern of the sectors as defined in a paper on the government’s
reduction in mortality and to see if the point estimate for poverty-reduction strategy.20,21 Data for trends in gross
the year 2004 differed from historical values or from the domestic product (GDP) per person were obtained from
period average. We also investigated Tanzania’s health- the Bank of Tanzania’s annual reports,22 the Penn World
system investments, including coverage of child-survival Tables,23 and the Tanzania public expenditure review.24
interventions between the late 1990s and 2000–04, and
examined other factors, not related to the health system, Statistical analysis
such as national economic growth, poverty reduction, We analysed the raw data from all four Tanzania DHS
food security, climate shock, fertility, maternal education, surveys (1992, 1996, 1999, and 2004)13–16 to generate several
and HIV/AIDS, that could plausibly have exerted large, estimates of mortality in children younger than 5 years
rapid effects on child survival. for every 1-year period before the respective survey back
to 1990, by use of direct methods based on complete birth
Methods histories. For every child recorded in these birth histories,
Data sources we computed survival for every month from birth until
To assess trends in mortality since 1990 we used all four either their fifth birthday or the date of the survey. We
Tanzanian demographic and health surveys, from 1992, grouped periods at risk and deaths for each calendar year,
1996, 1999, and 2004–05.13–16 These were nationally and constructed a separate life table for each year in the
representative cluster sample surveys that covered 8327, birth histories for which sufficient data were available to
7969, 3615, and 9735 households in 1992, 1996, 1999, and show, for a person at each age, the probability that they
2005, respectively. The surveys provided direct estimates would die before their next birthday. This generated
of child mortality through complete fertility (birth) 35 estimates of mortality over the 15-year period from 1990
histories of 32 877 women aged between 15 and 49 years. to 2004. We estimated trends in mortality from 1990
The surveys also provided detailed information about to 2004 by fitting Lowess regression25 of the natural log of
household demographics; asset ownership; dwelling mortality in children younger than 5 years [ln(5q0)] to
conditions; health and nutritional status of women and time with bandwidths ranging from 0·2 (representing
children; coverage of health-care services such as high sensitivity to recent data) to 2·0 (low sensitivity) and
immunisation, insecticide-treated nets, and maternal forecasted this trend for mortality from 2005 to 2015 with
and child health; and current knowledge and practices the same range of bandwidths. We calculated confidence
related to health. Survey data were obtained by trained intervals for probabilities with Greenwood’s formula.26
personnel, with the verbal informed consent of We obtained fiscal-year data on total health spending,
participants. To assess coverage of child-health both on-budget and off-budget, from the public-expenditure
interventions, we also used a 2003 survey on service reviews of the Tanzanian Ministry of Finance and Ministry
provision in Tanzania, which was a nationally of Health and Social Welfare.24 Spending data included all
representative facility-based survey of maternal and child domestic government health spending (including the
health and HIV/AIDS services.18 All the surveys provided government’s contribution to the national health insurance
cross-sectional data on intervention coverage in their fund) and all aid spending on health from official
respective years. documents. We did not include private out-of-pocket
We obtained data for poverty from Tanzanian household expenditure. We adjusted total government health
budget surveys in 1992 and 2002,19 which tracked the expenditure for each year with consumer price-index
progress of the government’s poverty-monitoring deflators on the 1998/99 base year to provide the total
strategy. These surveys sampled 4000 households government health expenditures per person per year. Thus,
141·5
160 epidemics, famine, or increased food insecurity, that
128·2
(deaths per 1000 livebirths)
this short period. Between 1999 and 2004, Tanzania more interventions, such as antenatal care an immunisation,
than doubled its public expenditure on health; such coverage was already high, and did not change.
increased expenditure has been strongly correlated with Modelling showed that a 33% reduction of mortality in
increased survival in children younger than 5 years in children younger than 5 years could be expected
developing countries, especially in poor people.37 between 1999 and 2004, from 129 to 86 deaths per
Increased public expenditure on health could also be 1000 livebirths. These effects would mainly be in
especially powerful in decentralised health systems when reduction of postneonatal mortality in children younger
such resources are targeted towards essential cost-effective than 5 years. The predicted failure to affect neonatal (and
interventions.38 Tanzania implemented such governance maternal) mortality draws attention to problems with the
shifts towards greater decentralisation in 2000, by continuum of care necessary to achieve MDGs. The
introducing sector-wide capitation grants that gave general scarcity of data and analyses continues to limit
districts substantial financial resources. This was perhaps programme efforts and monitoring of progress.
one of the most important distinctions in Tanzania’s Among factors not related to the health system, gains
health system between the 1990s and the 2000s, since it in wealth would be expected to exert a major effect on
opened opportunities for local problem solving and survival in children younger than 5 years. Tanzania has
provided resources for districts to selectively increase enjoyed many decades of political stability and, in recent
resources for key interventions, as has been shown in years, steady economic growth. Nevertheless, GDP per
pilot studies since 1996.38 person has increased by only 93 international dollars
Decentralisation allowed the introduction and scale-up (US$47) over the 5 years between 1999 and 2004. An
of new interventions such as the integrated management increase of this size corresponds to an expected decrease
of childhood illness, which facilitated adoption of new in mortality in children younger than 5 years of 2·2%, on
treatment policies for malaria that replaced failing the basis of a regression of GDP (in international dollars)
first-line treatments with more effective case management per person and mortality in children younger than 5 years
for the largest single cause of death for children. The for 45 sub-Saharan countries (data reanalysed from WHO
IMCI programme also assisted promotion of the use of statistics).27 Although important, this growth in national
insecticide-treated nets for malaria prevention. Sentinel wealth would be unlikely to account for much of our
districts had piloted the introduction of IMCI from 1997, finding of a 40% reduction in mortality, especially since
with full provision, increased use, and effective coverage the proportion of the population living below the absolute
by 1999–2000.39 Impact studies showed that, after a 2-year poverty line and food poverty line in the 1990s had
follow-up, IMCI was associated with 13% lower child improved only slightly in 2002. Although gains have been
mortality in pilot districts that had health-system made in the education of Tanzania’s current cohort of
strengthening than in other districts.40 Other pilot studies schoolchildren, child-health outcomes are affected by the
in Tanzania showed the high local effectiveness of educational status of parents, which had improved only
insecticide-treated nets for reduction of mortality in marginally by 2004. Early child-bearing and short
children of this age.41 birth-spacing both raise the risk of child mortality, and
Tanzania started nationwide scale-up of the total fertility rate, average age at first birth, adolescent
insecticide-treated nets in 1999 and of IMCI in 2000, and childbearing, and median birth intervals remained
changed its drug policy for malaria in 2001. Since malaria similar in the two periods. Hence changes in fertility
mortality in Tanzania is concentrated in postneonatal probably did not contribute to our findings of a large
infants younger than 5 years,42 the survival gains recorded improvement in child survival.
in the 2004–05 demographic and health survey were We did not find evidence of any major epidemics (for
highest for postneonatal infants, suggesting that example, of measles or meningitis) that might have
malaria-specific mortality reduction has made progress. occurred in the late 1990s but not in the early 2000s.
Moreover, several sentinel sites in Tanzania, which Conversely, adult and child mortality due to HIV/AIDS
monitor cause-specific mortality by use of continuous continued to increase slowly,43 and therefore differentials
longitudinal demographic surveillance systems, also in HIV/AIDS interventions might have affected overall
reported reductions in mortality in children younger mortality, since 25% of children who are born to
than 5 years before the findings of the 2004–05 HIV-positive mothers are infected. The PMTCT
demographic and health surveys, and detected declines programme is a proven cost-effective combination of
in malaria and acute febrile illness deaths in children strategies and interventions that can be tailored to specific
younger than 5 years.34,43 These findings add plausibility local conditions. These interventions and strategies,
to the hypothesis that the collective effect of a multifaceted including voluntary and confidential counselling and
approach to malaria contributed to child-survival gains testing, provision of antiretroviral drugs to HIV-positive
during this period.44 Coverage of other child-survival pregnant women, planning of safe delivery procedures,
interventions, such as vitamin A supplementation,45 and counselling about appropriate infant-feeding options,
exclusive breastfeeding, oral rehydration therapy and can reduce mother-to-child transmission by 50%.
iron supplementation for children, increased. For other However, in Tanzania access to HIV/AIDS interventions
such as voluntary counselling and testing, PMTCT, and We were unable to estimate the relative contributions
antiretrovirals was not yet sufficient as of 2004 to have of different factors in the health system to reduction of
affected child survival on a national scale. Epidemic child mortality since 2000. However, the collective weight
patterns, including HIV/AIDS and its response, can of so many positive changes in the health system, in the
therefore be excluded as an explanation for the reduction absence of other explanations, is compelling. Rather, we
in child mortality, and could even have worked against could ask why we would not expect to see gains in
this trend. survival.5 Broad, multifaceted progress in stewardship,
Nutrition can be determined by health systems (eg, public expenditure on health, decentralised financing,
micronutrient supplementation and other health sector resource allocation, and better coverage of essential
interventions) and by other factors (eg, food insecurity, child-survival services can work synergistically to effect
poverty, climate shocks, and natural disasters). We did important progress towards MDG 4 in low-income
not identify evidence of major events outside the health countries such as Tanzania. Increased health resources
system that could have contributed to changes in combined with strengthening of decentralised health
nutritional status in Tanzania during the study period. systems to ensure that life-saving interventions reach
However, the nutritional status of children did improve those in need is a key child-survival strategy.
slightly, possibly because of better access to various Contributors
general health interventions (eg, IMCI, insecticide-treated HM and DDS led the conceptualisation of the paper with contributions
nets, and vitamin A supplementation), and slight gains from all authors and wrote the first draft. PS compiled statistical data,
and HM, TS, and DDS did statistical analyses. JS, TJ, CM, GU, TB, and
in wealth. Improved nutritional status is likely to have CV contributed to the interpretation and writing of this manuscript. All
contributed to the reduced risk of mortality in children authors have seen and approved the final version.
younger than 5 years. Conflict of interest statement
If we assume that the trend is real, and is due to a We declare that we have no conflict of interest.
strengthening health system and increased access to key Acknowledgments
child-survival interventions, can this trend be continued? We thank the Government of Norway for encouragement and financial
It should be noted that the most recent demographic and assistance.
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