title: Malawi and Millennium Development Goal 4: a Countdown to 2015 country case study.
abstract: BACKGROUND
  Several years in advance of the 2015 endpoint for the Millennium Development Goals (MDGs), Malawi was already thought to be one of the few countries in sub-Saharan Africa likely to meet the MDG 4 target of reducing under-5 mortality by two-thirds between 1990 and 2015. Countdown to 2015 therefore selected the Malawi National Statistical Office to lead an in-depth country case study, aimed mainly at explaining the country's success in improving child survival.
  
  
  METHODS
  We estimated child and neonatal mortality for the years 2000-14 using five district-representative household surveys. The study included recalculation of coverage indicators for that period, and used the Lives Saved Tool (LiST) to attribute the child lives saved in the years from 2000 to 2013 to various interventions. We documented the adoption and implementation of policies and programmes affecting the health of women and children, and developed estimates of financing.
  
  
  RESULTS
  The estimated mortality rate in children younger than 5 years declined substantially in the study period, from 247 deaths (90% CI 234-262) per 1000 livebirths in 1990 to 71 deaths (58-83) in 2013, with an annual rate of decline of 5·4%. The most rapid mortality decline occurred in the 1-59 months age group; neonatal mortality declined more slowly (from 50 to 23 deaths per 1000 livebirths), representing an annual rate of decline of 3·3%. Nearly half of the coverage indicators have increased by more than 20 percentage points between 2000 and 2014. Results from the LiST analysis show that about 280,000 children's lives were saved between 2000 and 2013, attributable to interventions including treatment for diarrhoea, pneumonia, and malaria (23%), insecticide-treated bednets (20%), vaccines (17%), reductions in wasting (11%) and stunting (9%), facility birth care (7%), and prevention and treatment of HIV (7%). The amount of funding allocated to the health sector has increased substantially, particularly to child health and HIV and from external sources, but remains below internationally agreed targets. Key policies to address the major causes of child mortality and deliver high-impact interventions at scale throughout Malawi began in the late 1990s and intensified in the latter half of the 2000s and into the 2010s, backed by health-sector-wide policies to improve women's and children's health.
  
  
  CONCLUSIONS
  This case study confirmed that Malawi had achieved MDG 4 for child survival by 2013. Our findings suggest that this was achieved mainly through the scale-up of interventions that are effective against the major causes of child deaths (malaria, pneumonia, and diarrhoea), programmes to reduce child undernutrition and mother-to-child transmission of HIV, and some improvements in the quality of care provided around birth. The Government of Malawi was among the first in sub-Saharan Africa to adopt evidence-based policies and implement programmes at scale to prevent unnecessary child deaths. Much remains to be done, building on this success and extending it to higher proportions of the population and targeting continued high neonatal mortality rates.
  
  
  BACKGROUND
  Bill & Melinda Gates Foundation, WHO, The World Bank, Government of Australia, Government of Canada, Government of Norway, Government of Sweden, Government of the UK, and UNICEF.
authors.affiliation: Malawi National Statistics Office, Zomba, Malawi.
authors.forename: Mercy
authors.initials: M
authors.lastname: Kanyuka
authors.affiliation: Malawi National Statistics Office, Zomba, Malawi.
authors.forename: Jameson
authors.initials: J
authors.lastname: Ndawala
authors.affiliation: Malawi National Statistics Office, Zomba, Malawi.
authors.forename: Tiope
authors.initials: T
authors.lastname: Mleme
authors.affiliation: Malawi National Statistics Office, Zomba, Malawi.
authors.forename: Lusungu
authors.initials: L
authors.lastname: Chisesa
authors.affiliation: Malawi National Statistics Office, Zomba, Malawi.
authors.forename: Medson
authors.initials: M
authors.lastname: Makwemba
authors.affiliation: Data and Analytics, UNICEF, New York, NY, USA.
authors.forename: Agbessi
authors.initials: A
authors.lastname: Amouzou
authors.affiliation: Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Josephine
authors.initials: J
authors.lastname: Borghi
authors.affiliation: Malawi College of Medicine, Blantyre, Malawi.
authors.forename: Judith
authors.initials: J
authors.lastname: Daire
authors.affiliation: University College London, Institute for Global Health, London, UK; Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland.
authors.forename: Rufus
authors.initials: R
authors.lastname: Ferrabee
authors.affiliation: Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Hazel
authors.affiliation: Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Heidkamp
authors.affiliation: Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Hill
authors.affiliation: Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Melisa
authors.initials: M
authors.lastname: Martínez Álvarez
authors.affiliation: Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland.
authors.forename: Leslie
authors.initials: L
authors.lastname: Mgalula
authors.affiliation: Chancellor College, University of Malawi, Zomba, Malawi.
authors.forename: Spy
authors.initials: S
authors.lastname: Munthali
authors.affiliation: University College London, Institute for Global Health, London, UK.
authors.forename: Bejoy
authors.initials: B
authors.lastname: Nambiar
authors.affiliation: Malawi Ministry of Health (IMCI), Lilongwe, Malawi.
authors.forename: Humphreys
authors.initials: H
authors.lastname: Nsona
authors.affiliation: Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Lois
authors.initials: L
authors.lastname: Park
authors.affiliation: Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Neff
authors.initials: N
authors.lastname: Walker
authors.affiliation: Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland.
authors.forename: Bernadette
authors.initials: B
authors.lastname: Daelmans
authors.affiliation: Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Bryce
authors.affiliation: University College London, Institute for Global Health, London, UK. Electronic address: t.colbourn@ucl.ac.uk.
authors.forename: Tim
authors.initials: T
authors.lastname: Colbourn
mesh_terms: D002662:Child Health Services / Q000592:standards*; D046688:Child Mortality / Q000639:trends; D002675:Child, Preschool; D003140:Communicable Disease Control / Q000592:standards*; D005260:Female; D006040:Goals; D006801:Humans; D007223:Infant; D007226:Infant Mortality / Q000639:trends; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008427:Maternal Health Services / Q000592:standards*; D011787:Quality of Health Care / Q000592:standards*