title: Benchmarking health system performance across districts in Zambia: a systematic analysis of levels and trends in key maternal and child health interventions from 1990 to 2010.
abstract: BACKGROUND
  Achieving universal health coverage and reducing health inequalities are primary goals for an increasing number of health systems worldwide. Timely and accurate measurements of levels and trends in key health indicators at local levels are crucial to assess progress and identify drivers of success and areas that may be lagging behind.
  
  
  METHODS
  We generated estimates of 17 key maternal and child health indicators for Zambia's 72 districts from 1990 to 2010 using surveys, censuses, and administrative data. We used a three-step statistical model involving spatial-temporal smoothing and Gaussian process regression. We generated estimates at the national level for each indicator by calculating the population-weighted mean of the district values and calculated composite coverage as the average of 10 priority interventions.
  
  
  RESULTS
  National estimates masked substantial variation across districts in the levels and trends of all indicators. Overall, composite coverage increased from 46% in 1990 to 73% in 2010, and most of this gain was attributable to the scale-up of malaria control interventions, pentavalent immunization, and exclusive breastfeeding. The scale-up of these interventions was relatively equitable across districts. In contrast, progress in routine services, including polio immunization, antenatal care, and skilled birth attendance, stagnated or declined and exhibited large disparities across districts. The absolute difference in composite coverage between the highest-performing and lowest-performing districts declined from 37 to 26 percentage points between 1990 and 2010, although considerable variation in composite coverage across districts persisted.
  
  
  CONCLUSIONS
  Zambia has made marked progress in delivering maternal and child health interventions between 1990 and 2010; nevertheless, substantial variations across districts and interventions remained. Subnational benchmarking is important to identify these disparities, allowing policymakers to prioritize areas of greatest need. Analyses such as this one should be conducted regularly and feed directly into policy decisions in order to increase accountability at the local, regional, and national levels.
authors.affiliation: University of California, Berkeley (UC Berkeley), Berkeley, CA, USA. kecolson@gmail.com.
authors.forename: Katherine Ellicott
authors.initials: KE
authors.lastname: Colson
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. ladwyer@uw.edu.
authors.forename: Laura
authors.initials: L
authors.lastname: Dwyer-Lindgren
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. n_achoki@yahoo.com.|Ministry of Health of Botswana, Gaborone, Botswana. n_achoki@yahoo.com.
authors.forename: Tom
authors.initials: T
authors.lastname: Achoki
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. nf4@uw.edu.
authors.forename: Nancy
authors.initials: N
authors.lastname: Fullman
authors.affiliation: USAID, Washington, DC, USA. matthew.schneider1324@gmail.com.
authors.forename: Matthew
authors.initials: M
authors.lastname: Schneider
authors.affiliation: Clinton Health Access Initiative, Lusaka, Zambia. pmulengamusonda@yahoo.com.
authors.forename: Peter
authors.initials: P
authors.lastname: Mulenga
authors.affiliation: Department of Economics, University of Bergen, Bergen, Norway. peterhangoma555@yahoo.com.|Department of Economics, University of Zambia, Lusaka, Zambia. peterhangoma555@yahoo.com.
authors.forename: Peter
authors.initials: P
authors.lastname: Hangoma
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. marieng@uw.edu.
authors.forename: Marie
authors.initials: M
authors.lastname: Ng
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. fmasiye@yahoo.com.|Department of Economics, University of Zambia, Lusaka, Zambia. fmasiye@yahoo.com.
authors.forename: Felix
authors.initials: F
authors.lastname: Masiye
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA. gakidou@uw.edu.
authors.forename: Emmanuela
authors.initials: E
authors.lastname: Gakidou
mesh_terms: D019985:Benchmarking; D002648:Child; D002669:Child Welfare / Q000706:statistics & numerical data*; D003625:Data Collection; D005190:Family; D005260:Female; D006801:Humans; D007223:Infant; D008427:Maternal Health Services / Q000706:statistics & numerical data*; D008429:Maternal Welfare / Q000706:statistics & numerical data*; D009313:National Health Programs / Q000706:statistics & numerical data*; D011247:Pregnancy; D012959:Socioeconomic Factors; D015024:Zambia