Benchmarking health system performance across states in Nigeria: a systematic analysis of levels and trends in key maternal and child health interventions and outcomes, 2000-2013.
BACKGROUND
Nigeria has made notable gains in improving childhood survival but the country still accounts for a large portion of the world's overall disease burden, particularly among women and children. To date, no systematic analyses have comprehensively assessed trends for health outcomes and interventions across states in Nigeria.


METHODS
We extracted data from 19 surveys to generate estimates for 20 key maternal and child health (MCH) interventions and outcomes for 36 states and the Federal Capital Territory from 2000 to 2013. Source-specific estimates were generated for each indicator, after which a two-step statistical model was applied using a mixed-effects model followed by Gaussian process regression to produce state-level trends. National estimates were calculated by population-weighting state values.


RESULTS
Under-5 mortality decreased in all states from 2000 to 2013, but a large gap remained across them. Malaria intervention coverage stayed low despite increases between 2009 and 2013, largely driven by rising rates of insecticide-treated net ownership. Overall, vaccination coverage improved, with notable increases in the coverage of three-dose oral polio vaccine. Nevertheless, immunization coverage remained low for most vaccines, including measles. Coverage of other MCH interventions, such as antenatal care and skilled birth attendance, generally stagnated and even declined in many states, and the range between the lowest- and highest-performing states remained wide in 2013. Countrywide, a measure of overall intervention coverage increased from 33% in 2000 to 47% in 2013 with considerable variation across states, ranging from 21% in Sokoto to 66% in Ekiti.


CONCLUSIONS
We found that Nigeria made notable gains for a subset of MCH indicators between 2000 and 2013, but also experienced stalled progress and even declines for others. Despite progress for a subset of indicators, Nigeria's absolute levels of intervention coverage remained quite low. As Nigeria rolls out its National Health Bill and seeks to strengthen its delivery of health services, continued monitoring of local health trends will help policymakers track successes and promptly address challenges as they arise. Subnational benchmarking ought to occur regularly in Nigeria and throughout sub-Saharan Africa to inform local decision-making and bolster health system performance.
Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA. awollum@uw.edu.
Alexandra
A
Wollum
Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA. royburst@uw.edu.
Roy
R
Burstein
Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA. nf4@uw.edu.
Nancy
N
Fullman
Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA. ladwyer@uw.edu.
Laura
L
Dwyer-Lindgren
Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA. gakidou@uw.edu.
Emmanuela
E
Gakidou
D000328:Adult; D019985:Benchmarking; D002648:Child; D000067576:Child Health / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007114:Immunization; D007223:Infant; D008288:Malaria / Q000517:prevention & control; D009549:Nigeria; D011247:Pregnancy; D011295:Prenatal Care / Q000706:statistics & numerical data*; D014611:Vaccination