Progress in Child Health Across Districts in Zambia

UNIVERSITY OF ZAMBIAINSTITUTE FOR HEALTH METRICS AND EVALUATIONUNIVERSITY OF WASHINGTON

Assessing Impact, Improving HealthProgress in Child Health Across Districts in ZambiaA REPORT OF THE MCPA PROJECT

This report was prepared by the Institute for Health Metrics and Evaluation (IHME) and the Department of Economics at the University of Zambia (UNZA). This work is intended to provide in-formation on levels and trends in under-5 mortality and coverage of key child health interventions across districts in Zambia. The estimates may change following peer review. The contents of this publication may not be reproduced in whole or in part without permission from IHME.

Institute for Health Metrics and Evaluation2301 Fifth Ave., Suite 600Seattle, WA 98121USA

Telephone: +1-206-897-2800Fax: +1-206-897-2899Email: comms@healthmetricsandevaluation.orgwww.healthmetricsandevaluation.org

Printed in the United States 2014 Institute for Health Metrics and Evaluation

1TABLE OF CONTENTS3 Acronyms

4 Termsanddefinitions

5 Executivesummary

6 Introduction

8 Mainfindings

12 Conclusionsandpolicyimplications

13 References

14 Annex1.OverviewoftheMCPAanalyticalapproachandmethods

15 Districtprofiles

17 Centralprovince

31 Copperbeltprovince

53 Easternprovince

71 Luapulaprovince

87 Lusakaprovince

97 Northernprovince

123 North-westernprovince

139 Southernprovince

163 Westernprovince

AssessingImpact,ImprovingHealthProgress in Child Health Across Districts in ZambiaA REPORT OF THE MCPA PROJECT

2ABOUT IHME

ACKNOWLEDGMENTS

ABOUT THIS REPORT

The Institute for HealthMetrics and Evaluation (IHME) is anindependentglobalhealth researchcenterat theUniversityofWashington thatprovides rigorousandcomparablemea-surementoftheworldsmostimportanthealthproblemsandevaluates thestrategiesused toaddress them. IHMEmakesthisinformationfreelyavailablesothatpolicymakershavetheevidencetheyneedtomakeinformeddecisionsabouthowtoallocateresourcestobestimprovepopulationhealth.

To express interest in collaborating or request furtherinformationontheMalariaControlPolicyAssessment(MCPA)projectinZambia,pleasecontactIHMEat:

InstituteforHealthMetricsandEvaluation2301FifthAve.,Suite600Seattle,WA98121USA

Telephone:+1-206-897-2800Fax:+1-206-897-2899E-mail:comms@healthmetricsandevaluation.orgwww.healthmetricsandevaluation.org

Assessing Impact, Improving Health: Progress in Child Health Across Districts in Zambia provides the most up-to-date re-sultsfromtheMCPAprojectinZambia,includingdistrict-leveltrendsforarangeofindicatorsandtheimpactofmalariacon-trolandotherchildhealthinterventionsonunder-5mortality.Thisreportexpandsuponthe2011reportproducedbyIHMEand the University of Zambia (UNZA), Maternal and Child Health Intervention Coverage in Zambia: the Heterogeneous Picture.

TheMCPAprojectwasledbyEmmanuelaGakidouatIHMEandFelixMasiye atUNZA.Data collationwasprimarily con-

ductedbyPeterHangomaandPeterMulenga,researchersattheDepartmentofEconomicsatUNZA,andFrankKukungaattheCentralStatisticalOffice(CSO).Trendsinunder-5mortalitywereproducedbyLauraDwyer-Lindgrenat IHME,withcon-tributionsfromCaseyOlivesoftheUniversityofWashington.AtIHME,interventioncoverageanalyseswereconductedbyK.EllicottColson,withcontributions fromLauraDwyer-Lind-gren, Tom Achoki, Nancy Fullman, and Matthew Schneider(nowatUSAID).ThecausalattributionanalysiswasperformedbyMarieNgandK.EllicottColson.ThisreportwaswrittenbyNancyFullman,withcontributionsfromWilliamHeisel.

TheMCPAproject inZambia isacollaborationbetween theDepartmentofEconomicsatUNZAand IHMEat theUniver-sityofWashington.ThisprojecthasbenefitedgreatlyfromkeyinputsandsupportfromtheMinistryofHealth(MOH),theNa-tionalMalariaControlCentre(NMCC),CSO,andtheChurchesHealthAssociationofZambia(CHAZ),inZambia.Wearemostgratefultotheseorganizations,especiallyfortheirwillingnessto facilitate data access and provide crucial content knowl-edge.

We thank the MCPA Advisory Group, which consists ofinternationalandlocalstakeholderswhocontributedtowardrefining the projects research concept and framework.WealsothanktheMalariaControlandEvaluationPartnership in

Africa(MACEPA)teaminZambiaforfacilitatingdataaccess.AtIHME,wewishtothankHeatherBonander,AnnieHaakenstad,andKelseyPierce formanaging theproject; PatriciaKiyonoformanaging theproductionof this report; BrianChildress, Adrienne Chew, and KateMuller for editorial support; andRyanDiazandAnnKumasaka forgraphicdesign.We thankSepoKusiyoatUNZA foradministrativesupportof theZam-bianMCPAteam.

Funding for this research came from the Bill &MelindaGatesFoundation.

3Acronyms AIDS AcquiredimmunodeficiencysyndromeANC4 Antenatalcare,aminimumoffourvisitsBCG BacillusCalmette-GurinvaccineCSO CentralStatisticalOfficeDPT3 Diphtheria-pertussis-tetanusvaccine(threedoses)GPR GaussianProcessRegressionHIV HumanimmunodeficiencyvirusIHME InstituteforHealthMetricsandEvaluationIPTp2 Intermittentpreventivetherapyinpregnancy,aminimumoftwodosesIRS IndoorresidualsprayingITN Insecticide-treatednetJICA JapanInternationalCooperationAgencyMCPA MalariaControlPolicyAssessmentMOH MinistryofHealthMSL MedicalStoresLimitedNMCC NationalMalariaControlCentrePCA PrincipalcomponentanalysisPMTCT Preventionofmother-to-childtransmissionofHIVSBA SkilledbirthattendanceUNZA UniversityofZambia

4Terms and definitionsAll-cause under-5 mortality: theprobability (expressed as the rateper 1,000 livebirths)thatchildrenbornalivewilldiebeforereachingtheageof5years

Antenatal care (ANC4) coverage: theproportionofwomen15to49yearsoldwhohadfourormoreantenatalvisitsatahealthfacilityduringpregnancy

BCG immunization coverage: theproportionofchildrenunder5yearsoldwhohavebeenvaccinatedagainsttuberculosis

Childhood underweight: the proportion of children under 5 years old who aretwo or more standard deviations below the internationalanthropometric reference population median of weight forage

DPT3 coverage: the proportion of children 12 to 59 months old who havereceived three doses of the diphtheria-pertussis-tetanus(DPT)vaccine

Exclusive breastfeeding coverage: the proportion of children who were exclusively breastfedduringtheirfirstsixmonthsafterbirth

Indoor residual spraying coverage: the proportion of households that were sprayed with aninsecticide-basedsolutioninthelast12months

Insecticide-treated net (ITN): anet treatedwithan insecticide-basedsolutionthat isusedforprotectionagainstmosquitosthatcancarrymalaria

Intermittent preventive therapy in pregnancy, two doses (IPTp2): theproportionofpregnantwomenwhoreceivedatleasttwotreatmentdosesof Fansidar (sulfadoxine/pyrimethamine) atantenatalcarevisitsduringpregnancy

Intervention coverage: theproportionofindividualsorhouseholdswhoreceivedaninterventionthattheyneeded

ITN ownership: theproportionofhouseholdsthatownatleastoneITN

ITN use by children under 5: theproportionofchildrenunder5yearsoldwhosleptunderanITNthepreviousnight,asreportedbyhouseholdheads

Measles immunization coverage: the proportion of children 12 to 59 months old who havereceivedmeaslesvaccination

Pentavalent immunization coverage: the proportion of children 12 to 59 months old who havereceivedthepentavalentvaccine,which includesprotectionagainst diphtheria-pertussis-tetanus (DPT), hepatitis B, andHaemophilus influenzae typeb

Polio immunization coverage: the proportion of children 12 to 59 months old who havereceivedthreedosesoftheoralpoliovaccine

Prevention of mother-to-child transmission of HIV (PMTCT):the receipt of antiretroviral drugs as prophylaxis to reducethe risk of mother-to-child transmission of HIV among HIV-positivepregnantwomen

Skilled birth attendance coverage: theproportionofpregnantwomen15 to49yearsoldwhodelivered with a skilled birth attendant (a doctor, nurse,midwife,orclinicalofficer)

5Executive summaryZambiahasseenremarkable improvement inchildhoodsur-vivaloverthepasttwodecades.Whilethescale-upofmalariacontrol interventionshasbeenproposedasoneof thebig-gestdriversbehindthatimprovement,littleresearchhasbeendoneonhowmuchof the reduction in childhoodmortalitymaybeattributedtomalariacontrolandhowmuchisthere-sult of improvements inother childhealth interventions.Toaddressthisknowledgegap,theUniversityofZambia(UNZA)and the Institute for Health Metrics and Evaluation (IHME)worked together on theMalaria Control Policy Assessment(MCPA) project. The goal ofMCPAwas to harness existingdatainZambiaanduserigorousstatisticalmethodstoquan-tify the impact of malaria control and other child healthinterventionsonunder-5mortalitytrendsacrossdistricts.

Wefoundthatbetween1990and2010,acombinationofrapidlyscaledupchildhealthinterventionscontributedtoanadditional11%ofdeclinesinunder-5mortalityacrossZambia.We lookedat thecombinedeffectof these interventionsbe-cause the scale-up in ownership of insecticide-treated nets(ITNs)anduseofindoorresidualspraying(IRS)coincidedwiththescale-upinthreeotherkeychildhealthinterventions:thepentavalentvaccine,exclusivebreastfeeding,andservicestohelppreventmother-to-child transmissionofHIV (PMTCT)athealthfacilities.Isolatingthespecificimpactofeachinterven-tion isnotpossible.Nevertheless, jointly, these interventionscontributedsignificantlytothereductionofunder-5mortalitythroughoutthecountry.

TheMCPAprojectinZambiaproduceddistrict-leveltrendsforkeychildhealthoutcomesandinterventionsfrom1990to2010.This is thefirst time thatannualestimates forunder-5mortalityandinterventioncoveragehavebeengeneratedatthedistrict level. In this report,districtprofilesdetail trendsin child health over time and benchmark the districts per-formance across indicators.With this information, local andnationalpolicymakersandhealthofficials can identify areasofsuccessfulhealthservicedeliveryanddetectearlysignsofdeclininginterventioncoverageorstalledprogress.

This report shows that Zambia is succeeding on severalfrontsinchildhealth.First,countrywidereductionsinunder-5mortalitywerealsoaccompaniedbyimprovementsinequity

acrossdistricts,assomeofthedistrictswiththehighestmor-talityratesin1990recordedsomeofthegreatestdeclinesby2010.Second,coverageofkeymalariacontrolinterventions,such as ITN ownership, increased dramatically inmany dis-tricts.Third,themajorityofdistrictsweresuccessfulinquicklyincreasing coverage of the pentavalent vaccine after its in-troduction in 2005. Finally, rates of exclusive breastfeedingmarkedly rose in most districts, reflecting the countrys in-vestments in improving child nutrition and breastfeedingpractices(WBTi2008).

ThesesuccesseswereaccompaniedbyconcerningtrendsforthreekeychildhealthinterventionsinZambia.First,mostdistrictssawadeclineinthe2000sinantenatalcare(ANC4),which is theproportionofpregnantwomen15 to49 yearsold who had four or more visits to a health facility duringpregnancy. This finding is particularlyworrisomegiven thatdistrictsgenerallyincreasedlevelsofANC4duringthe1990s.Second, coverage of polio immunization dropped in someof thedistricts that are consideredathigh risk forpolio im-portationfromneighboringcountries.Third,insomeareasofZambia, skilledbirthattendancedeclined tovery low levels.Targeting these areas for improvement shouldbe aprioritytoensurethatthecountrysachievementsinchildhealthcon-tinueintothepresentdecade.

Withafocusondistricts,findingsfromtheMCPAprojectin Zambia provide side-by-side comparisons of health per-formanceover time, geography, and intervention type.Thechild health landscape is remarkably heterogeneous acrossdistricts,highlightingtheneedforcontinuousandtimelyas-sessmentofdistrict-leveltrends.Withregularlycollectedandanalyzed district health information, policymakers can havetheevidencebasetomaketargeted,data-drivendecisionsforachievinggreaterandmoreequitablehealthgainsinZambia.

6IntroductionOver the past decade, Zambias child health and develop-ment landscape has been substantially reshaped by newprograms, interventions, and priorities, including extensivemalariacontrolprograms. Inorder to fullyunderstandwhathascontributedtoZambiasprogress inunder-5mortality, itisimportanttocomprehensivelyaccountforalleffortstoim-provechildhealth.

TheMCPAprojectinZambiahadtwomainobjectives:

1) Determine what proportion of the decline in all-causeunder-5 mortality in Zambia was attributable to thescale-upofmalariacontrolinterventions,whileaccountingfor a range of other key child health interventions andnon-healthfactors.

2) Assessthisimpactatthedistrictlevelbetween1990and2010.

Inordertoachievetheseobjectives,annualestimatesofdistrict-level trends from 1990 to 2010 were systematicallygenerated foreachof the72districts inZambiaandacrossa range of key child health outcomes and interventions.Detaileddescriptionsofthefindingsforeachdistrictarepre-sented in this report.District-leveldatacanbedownloadedfrom IHMEs Global Health Data Exchange: http://ghdx.healthmetricsandevaluation.org/.

TheMCPAprojectsoughttouseallavailabledatasources,whicharepresentedinTable1.Theseanalysesaimedtomakefull useof thebest availabledata in Zambia. Provincial esti-matesof under-5mortality and intervention coveragewerepreviouslyavailable,butforthefirsttimedistrict-leveltrendswerederivedfromthesedatasourcesusingrobuststatisticalmethods.Annex1providesanoverviewoftheanalyticalap-proachusedtogeneratetheestimatesinthisreport.

BOX 1MAIN FINDINGS FROM THE MCPA PROJECT IN ZAMBIA

Under-5mortalitysubstantiallydeclinedthroughoutZambiafrom1990to2010.Someofthegreatestprogresswasrecordedindistrictswiththehighestlevelsofunder-5mortalityin1990.

Coverage of malaria control interventions rapidly increased, especially between 2005 and 2010.ThesegainsincoveragewereobservedthroughoutZambia.

Atthesametimemalariainterventionswerescaledup,Zambiaalsosuccessfullyincreasedlevelsofcoverageforthreenon-malariachildhealthinterventions:thepentavalentvaccine,exclusivebreast-

feeding,andtheavailabilityofPMTCTservicesathealthfacilities.

Together,theserapidlyscaledupinterventionswereresponsibleforan11%reductionintheunder-5mortalityratefrom2000to2010.Sustaininghighcoverageoftheseinterventionsiscriticalforchild

healthinZambia.

Amidstthecountryshealthsuccesses,someworrisometrendsemergedthatwarrantattention.Mostdistrictssawsharpdeclinesinantenatalcarevisitsduringthe2000s,andskilledbirthattendancefell

toverylowlevelsinseveralplaces.Othersexperiencedaminimalscale-upofthepentavalentvaccine,

andsomeofthehigh-riskdistrictsforpolioimportationrecordeddropsinpolioimmunizationcov-

erage.Addressingthesegapsinhealthserviceprovisioniscrucialtomaintainingthecountrysgains

inchildhealth.

7Table 1. Data sources used in the MCPA project

Anearlierversionofthisreportwaspublishedin2011,Ma-ternal and Child Health Intervention Coverage in Zambia: the Heterogeneous Picture,andfocusedoninterventioncoveragetrendsbetween1990and2010.Thepresentreportprovidesabroaderrangeofupdatedresults,includingunder-5mortality

and coverageof thepentavalent vaccine, anddrills deeperinto Zambias trends in child health at the district level. Fur-ther,thepresentreportquantifiesthecontributionofmalariacontrolandotherkeychildhealth interventions toZambiasreductionsinunder-5mortality.

DATA SOURCE YEARS REPRESENTED

SURVEYS

DemographicandHealthSurvey(DHS) 1992,1996-1997,2001-2002,2007

MalariaIndicatorSurvey(MIS) 2006,2008,2010,2012

MultipleIndicatorClusterSurvey(MICS) 1999

LivingConditionsMonitoringSurvey(LCMS) 1996,1998,2002-2003,2004-2005,2006,2010

HealthFacilityCensus JapanInternationalCooperationAgency(JICA)(2005-2006)

SexualBehaviorSurvey(SBS) 2005,2009

HouseholdHealthCoverageSurvey 2008

NetmarkSurveyreports 2000,2004

POPULATION CENSUSES

Nationalcensus 1990,2000,2010

ADMINISTRATIVE SOURCES

HealthManagementInformationSystem(HMIS) 2000-2008;2009

Malariainterventiondatabases NationalMalariaControlCentre(NMCC)(2005-2010)

Facility-levelPMTCTservices NationalAIDSCouncilquarterlystatusreport(2005-2009)

HIV/AIDSprojections CentralStatisticalOffice(CSO)(2005)

Drugsupplyanddeliveryrecords MedicalStoresLimited(MSL)(2007-2010)

Precipitationdata GlobalPrecipitationClimatologyCentre(1986-2012)

Malariaendemicity(PfPR2-10) MalariaAtlasProject(2007,2010)

8Main findings

Under-5 mortality declines observed across districts, accompanied by reductions in inequities Zambia made substantial progress in improving child sur-vivalbetween1990and2010.Atthenationallevel,all-causeunder-5 mortality decreased by 37%, from 174 deaths per1,000 livebirths in1990 (95%CI: 168, 181) to109 in2010(95%CI:104,116).Alldistrictssawreductionsintheirlevelsofunder-5mortalityduringthistime.Moreover,manyofthedistrictswith thehighest levelsofunder-5mortality in1990showedthegreatestdeclinesby2010.Figure1depictshowthe range in under-5mortality across districts has becomenarrower.

In 1990, levels of under-5 mortality spanned from 125deaths per 1,000 live births (95%CI: 97, 161) to 276 (95%CI:220,338)indifferentdistricts.Twentyyearslater,thisgapsubstantiallytightened,witharangeof83deathsper1,000livebirths(95%CI:60,113)to150(95%CI:109,203).Thedif-ferencebetweenthedistrictwiththehighestlevelofunder-5mortalityandthelowestwasmorethanhalvedfrom1990to2010 (dropping fromadifferenceof 151 to 67), illustratinghowZambiasprogressinreducingunder-5mortalitywasalsoassociatedwithdecreasedhealthinequitiesacrossdistricts.

Despitetheseimprovements,itisworthnotingthatsomedistricts and regionsdocumented lessprogress.Districts inNorthernprovincehadveryhigh levelsofunder-5mortalityin 1990, and though many recorded large declines, theirratesstillremainedamongthehighestinthecountryin2010(greater than 120 deaths per 1,000 live births). Additionalefforts toreduceunder-5mortalityneedtobeprioritized inthesedistricts.

Malaria interventions are rapidly scaled up in Zambia, but most districts fall short of national targetsCoverageofmalariainterventionsgreatlyincreasedthrough-

outZambiaafter2000,withmostofthegainsoccurringsince2005. Nationally, the proportion of households that eitherownedatleastoneITNorreceivedIRSincreasedfrom8%in2000to37%in2005andthenrapidlyclimbedto71%in2010.Coverage of intermittent preventive therapy in pregnancy(IPTp2)quicklyrosefrom16%in2002toaround70%in2008.

In theearly2000s, coverageofmalaria control interven-tionswasverylowthroughoutZambia,withonlyafewdistrictsbenefitingfromITNpilotprogramsandearlyimplementationofIRS.By2010,however,alldistrictshadcoveragelevelsex-ceeding55%forhavingeitherITNsorIRS.Figure2showstheriseincoverageofmalariacontrolfrom2000to2010.

Districts sawawide varietyof trends in IPTp2 coverageduringthe2000s. IPTp2levelsroserapidly inmanydistrictsthroughout the 2000s.Others saw an increase in coverageandthenalevelingoffby2010.Athirdgroupofdistrictsex-perienced substantial declines in coverage during the late2000s.Last,asubsetofdistrictsrecordedverysmallchangesinIPTp2coverageduringthisperiod.

ZambiasNational Malaria Strategic Plan, 2006-2010 setseveralmalaria intervention coverage targets to achieveby2010, including (1)80%ofhouseholdswithat least threeITNs; (2)85%ofeligiblehouseholds in15 targetdistrictshavingreceivedIRS;(3)80%ofpregnantwomenreceiving2dosesofFansidar/SP(IPTp2);and(4)80%ofchildrenunder5yearsoldsleepingunderanITNorresidinginahousewithIRS(MOH2006).Thesetargetswereveryambitious,anddespitemarkedprogresssince2000,nodistrictachievedallfourtargetsin2010.Onlyfivedistrictsreachedtwoofthefourtargets.Table2displaysthe28districtsthatmetoneormoreofthesetargetsin2010.Thetargetthatwasmostfrequentlymetwas the third target,with16districts achievingat least80%IPTp2coveragein2010.

Figure 1. District-level estimates of all-cause under-5 mortality for 1990, 2000, and 2010

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GEOGRAPHY MALARIA INTERVENTION TARGETS

OWNERSHIP IRS UNDER-5 ITN PROVINCE DISTRICT OF 1 ITN* COVERAGE** IPTP, 2 DOSES USE OR IRS

Central Kabwe 81%

Mkushi 92%

Copperbelt Chingola 93%

Kalulushi 83%

Kitwe 87% 81%

Lufwanyama 91%

Masaiti 89%

Mpongwe 89%

Mufulira 80% 85%

Ndola 94%

Eastern Chadiza 81% 81%

Chama 90%

Katete 85% 81%

Mambwe 90% 89%

Petauke 80%

Luapula Chiengi 80%

Milenge 80%

Lusaka Chongwe 87%

Kafue 90%

Luangwa 89%

North-western Mufumbwe 82%

Northern Mpulungu 87%

Mungwi 84%

Nakonde 81%

Southern Livingstone 90%

Western Lukulu 96%

Mongu 89%

Senanga 88%

Table 2. District attainment of 2010 malaria intervention targets

Notes:*TheNMCCgoalwasownershipofatleastthreeITNsby2010.

**TheNMCCgoalwas85%coverageofeligiblehouseholdsby2010.BasedonMCPAanalyses,nodistrictreached85%IRScoverage; however,householdeligibilitycouldnotbeascertained.

1 0

Scale-up of the pentavalent vaccine varies, polio immunization falls in some areasJustlookingatthenationallevel,trendsinimmunizationcov-eragegenerallypointtoprogress.Butatthedistrictlevel,wesee a wide range of trends, with progress, stagnation, andtroublingdeclinesincoverage.

ThepentavalentvaccinewasformallyintroducedinZambiain2005,andthecountryachieved67%coveragein2010.Atthedistrictlevel,coverageofthepentavalentvaccinerangedfromaslowas22%(95%CI:8%,44%)toashighas90%(95%CI: 81%, 96%) in 2010, with some districts showing strongprogresssince2005andothersshowingminimalgainsincov-erage.Figure3depicts this range forpentavalentcoveragein2010.ManyofthelargestgainswereobservedinEasternprovince, while several districts in North-western provincecontinued tohave someof the lowest levelsofpentavalentcoveragein2010.Identifyinghowtoimprovethedeliveryoruptakeofthepentavalentvaccineforthesedistrictsoughttobeapriority.

In 2010, polio immunization coverage reached 81% atthe national level. However, coverage varied greatly acrossdistricts,rangingfrom24%(95%CI:10%,42%)to99%(95%CI:98%,100%).Zambiaspolio-freecertificationwasacceptedin2005,but severaldistricts thatborder theDemocraticRe-public of Congo (DRC) andAngola are considered at highrisk forpolio importation from thesecountries (WHO2011).Someofthesehigh-riskdistrictsrecordeddecliningcoverageofpolioimmunizationduringthe2000sandhadsomeofthelowest levelsofcoverage inZambia in2010. IfZambia is tooptimallyprotectitselffromimportedpolio,deliberateeffortsare needed to ensure that levels of polio immunization aresustainedathighlevelsinhigh-riskareas.

Figure 3. The proportion of children who received the pentavalent vaccine in 2010

Coverage of antenatal care substantial declined while skilled birth attendance gradually increasedAftermaintainingmoderatelyhighlevelsofANC4throughthe1990s,coverageinZambiadeclinedduringthe2000s,drop-pingto37%in2010.Atthesametime,skilledbirthattendance(SBA)coveragegraduallyincreased,risingto55%in2010.

For most districts, ANC4 coverage reached its highestlevelsbetween1990and2000,afterwhichcoveragemarkedlyfell.Figure4showsANC4coverageinmostdistrictsdroppingfrom higher levels (green) to much lower ones (shades oforange to red).Understandingwhysomanydistrictsexperi-encedsuchsharpdeclinesinantenatalcareshouldbeahighpriority inZambia. It is important tonote thata fewdistrictsdidincreaseANC4coverageduringthistime.It is likelythatmuchcouldbelearnedfromthesedistrictsaboutapproachestoANC4provisionandsupportofhealth-seekingbehaviors.

Trends inSBAcoveragewidelyvariedacrossdistricts,asdidtherangeinlevelsofcoveragethroughoutthecountry.In2010,SBAcoveragerangedfromlessthan1%to98%(95%CI:91%,100%).AboutfivedistrictshadverylowlevelsofSBA

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Figure 4. Coverage of four or more antenatal care visits (ANC4) in 2000, 2005, and 2010

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during the 1990s but then brought coverage to above thenationalaveragein2010.Approximately10recordedsteadygainsinSBAduringthe1990sbeforesharplyfallingtolevelsbelow20%.Anumberofdistrictshadconsistentlylowlevelsoverthetwodecades,whileafewmaintainedhighcoverage.Zambiawouldlikelybenefitfromfurtherinvestigationintothedistrictsdifferences in skilledbirthattendance trends,espe-ciallytodeterminewaystoimprovecoverageinplaceswhereSBAappearstobeminimal.

Breastfeeding increased to high levelsRatesofexclusivebreastfeedingrosesteadilythroughoutthe1990sand2000sbeforereaching80%nationallyin2010.Mostdistrictsfollowedthistrend,butthereweresomenotableex-ceptions. Some districts experienced an earlier scale-up ofexclusivebreastfeeding,recordingtheirhighestlevelsintheearly2000s,butsawcoveragequicklydeclineby2010.Afewdistricts,mostly in Eastern province, consistently trailed thenationalscale-upofexclusivebreastfeeding,barelyreaching60%in2010.

Rapid scale-up of key child health interventions contributes to declines in under-5 mortalityToassess the impactofmalariacontrolonunder-5mortalityin Zambia, theMCPA research team conducted a causal at-tribution analysis that included a full range of child healthinterventions and non-health factors. More details on themethodsandstatisticalmodelsusedcanbefoundinAnnex1.

The teamfoundthatZambiahadscaledupseveral inter-ventionsat thesametime.Figure5showshowgains in ITNand IRS coverage coincided with rising levels of the pen-tavalentvaccine,exclusivebreastfeeding,andtheavailabilityof PMTCT in health facilities. It was statistically impossibleto teaseout the individual effects of these interventionsonunder-5mortality. Instead, researchers created a compositeindicatorofrapidlyscaledupinterventions.

Figure 5. The scale-up of malaria control interventions and a subset of key child health interventions

After accounting for other factors (including socioeco- nomic indicators), rapidly scaled up interventions were sig- nificantly associated with Zambias reductions in all-causeunder-5mortality. Ifthecoverageoftheseinterventionshadremainedatlevelsobservedin2000,under-5mortalitywouldhave been 11% higher in 2010 (124 deaths per 1,000 livebirths(95%CI:118,129))thanwhatwasactuallyobservedforthatyear(109deathsper1,000livebirths(95%CI:104,116))(Figure6).

Figure 6. Trends in under-5 mortality as observed and predicted in the absence of rapidly scaled up interventions, 1990-2010

Thisfindingsuggeststhattherapidscale-upofthesefivematernalandchildhealthinterventionshastenedthedeclineofunder-5mortalityby1%peryear.Itisimportanttonotethatunder-5mortality rateswould have continued to decline inZambiabetween2000and2010,evenwithoutthescale-upoftheseinterventions.Infact,under-5mortalitydecreased14%between1990and2000,droppingfrom174deathsper1,000livebirths(95%CI:168,181)to149in2000(95%CI:144,156).GiventhedeclinesthatZambiaexperiencedinunder-5mor-tality from1990 to 2000,wewouldhavepredicted an18%decrease in under-5 mortality between 2000 and 2010. In-stead,withthescale-upofthesefiveinterventions,thecountryrecordeda26%declineduringthistime.Inotherwords,thesimultaneous scale-upof ITNs, IRS, thepentavalent vaccine,exclusivebreastfeeding,andPMTCTservicesacceleratedthedeclinesinunder-5mortalitybyanadditional1%peryear.

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Between 1990 and 2010, the health landscape in Zambiamarkedlychanged,and for themostpart, thesechangesre-flect progress and service delivery success throughout thecountry.Under-5mortalitysubstantiallydecreasedat thena-tionallevel,andthegapbetweendistrictswiththehighestandlowest under-5 mortality substantially decreased. These de-clinesinunder-5mortalitycanbetiedtoZambiassuccessfulefforts in expanding coverage for a subset of child healthinterventions:ITNownership,IRS,thepentavalentvaccine,ex-clusivebreastfeeding,andtheavailabilityofPMTCTservices.These five interventions were rapidly scaled up during the2000sandjointlycontributedtoanadditional11%reductioninall-causeunder-5mortalityinZambiabeyondwhatwouldhavebeenexpectedbasedonthecountrystrendsinunder-5mortality during the 1990s. The scale-up ofmalaria controlhas been a key part of Zambias improved health serviceenvironment, and sustaining high levels of malaria controlinterventions, alongsideother life-saving interventions, is ofcriticalimportance.

Amidstthesesuccesses,IHMEandUNZAidentifiedsometroublingtrendsthatwarrantfurtherpolicyattention.Overall,theproportionofpregnantwomenwhosoughtat least fourantenatalcarevisitsdrasticallydecreasedbetween2000and2010.SeveraldistrictsrecordedlevelsofANC4below20%in2010,whichsuggeststhatavastmajorityofwomenintheseplaces do not receive optimal antenatal care during preg-nancy.Knowingthatantenatalcareservicesarecloselylinkedto bettermaternal and child health outcomes (WHO 2003),ZambiashouldaddressthesedecliningtrendsinANC4.

Immunizationratesremainedat leastmoderatelyhighatthenational level,butsomedistrictsshowedconcerningde-clinesforcertainvaccines,namelypolio,andfellbehindinthescale-upofthepentavalentvaccine.AnumberofdistrictsthatareconsideredatriskforpolioimportationfromtheDRCandAngola recorded recent declines in immunization coverage.Several districts showed minimal gains in coverage of the

pentavalentvaccine, fallingwellbelow thenationalaveragein2010.Prioritizingtheaccelerationofpentavalentcoverageindistricts laggingbehindthenationaltrendshouldbecon-sidered.

Zambiasnewmalariastrategicplanmapsoutanambitiousgoal towarda malaria-freeZambia (MOH2011), forwhichuniversal coverageof ITNsor IRS and increasing IPTp fromtwotothreedoses(IPTp2toIPTp3)arenewinterventiontar-getsfor2015.GiventhatfewerthanhalfofZambiasdistrictsachievedatleastoneofthemalariainterventioncoveragetar-getsfor2010,thecountrymayneedtoconsiderstrategiestofurtherexpandandsustainhigher levelsofmalaria interven-tioncoverageinordertomeetits2015goals.

As demonstrated through the MCPA project in Zambia,nationaltrendscanmasksignificantdifferencesatthedistrictlevel.Thedistrictprofiles included in this reportprovidea data-drivenfoundationforbenchmarkingdistrictperformanceandtargetingareasfor improvement. It is importantforgov-ernments toprioritizemonitoringanddatagatheringat thedistrictleveltomakefutureanalysesmorerobustandtopro-videcriticalinputsfordecision-makingandpriority-settingbydistricthealthoffices.

TomaintainandfurtheracceleratethehealthgainsZambiahas made in child survival, continued efforts dedicated todeliveringa rangeofhealth interventions, includingmalariacontrol,areneeded.Theregularandtimelycollectionofdis-trict health datawill be crucial for guiding policy decisionsandresourceallocation.Thecountrys investments innation-widesurveysservedasthecornerstonefortheanalysesinthisreport,and theyare likely to remainavital sourceofhealthdataalongsideZambiashealthinformationsystems.Byusingitsdistrict-leveldataandfocusingonhealthgapsexperiencedby its districts, Zambia is in the position to further accel-erateprogress inchildhoodsurvivalandtopromotegreaterequalityinhealthattainmentthroughoutthecountry.

Conclusions and policy implications

1 3

ReferencesTheWorldBreastfeedingTrendsInitiative(WBTi).Zambia Country Assessment Report 2008.NationalFoodand NutritionCommission/IBFANAfrica,2008.Availableat:http://www.worldbreastfeedingtrends.org/report/WBTi-Zambian-2008.pdf[AccessedFebruary2014].

WorldHealthOrganization(WHO).Antenatal Care in Developing Countries: Promises, Achievements, and Missed Opportunities: an Analysis of Trends, Levels, and Differentials, 1990-2001.Geneva,Switzerland:WHO,2003.

WorldHealthOrganization(WHO).Annual Report of the WHO Country Office Zambia, 2011.Lusaka,Zambia:WHO,2011.

ZambiaMinistryofHealth(MOH).National Malaria Strategic Plan 20062011: A Road Map for RBM Impact in Zambia. Lusaka,Zambia:MOH,2006.

ZambiaMinistryofHealth(MOH).National Malaria Strategic Plan 20112015: Consolidating Malaria Gains for Impact. Lusaka,Zambia:MOH,2011.

1 4

Inordertocomprehensivelyassesstheimpactofmalariacon-trolonunder-5mortalityinadata-driven,systematicway,theMCPAresearchteamsmethodologicalframeworktookplaceinthreemainsteps:

(1) Collating data and generating source-specific esti-mates. TheMCPA research teambrought togetherabroadrange of data sources, including surveys, population cen-suses,andadministrativesources,togeneratesource-specificestimatesforall indicatorsof interest. Intotal,20householdsurveys,onehealthfacilitycensus,threepopulationcensuses,and two administrative sources (National Malaria ControlCentreindoorresidualsprayingdatabaseandfacilityPMTCTservicesfromtheNationalAIDSCouncil)wereincludedinthefinalanalysis.

(2) Estimating trends for 72 districts from 1990 to 2010. GiventherangeofdatatypesassembledfortheMCPAproject,statisticalmodelingapproacheshad tobeused inorder tosynthesizetheestimatesfromthesedifferentdatasourcesintoaunifiedtrend.Demographicmethodsforanalyzingbirthhis-torydatawerecombinedwithsmallareaestimationmodelingtogeneratedistrict-leveltrendsforall-causeunder-5mortality.Atwo-stepmethodinvolvingspatio-temporalsmoothingandGaussianProcessRegression(GPR)wasusedtoproducedis-trict-level trends for intervention coverage and non-healthindicators.

(3) Conducting causal attribution analyses. Many models and combinations of covariates were rigorously tested inorder to identify the most robust and valid model for as-sessing the relationship between declines in mortality andindividual health interventions and non-health indicators.Thetypesofmodelsthatwereexploredincludedsingle-andmultistage linearmodels, lasso, functionaldataanalysis,firstdifferences, differences-in-differences, structural equationsmodeling,andfactoranalysis.Themodelthatwasultimatelyselectedisalinearmodelwithbootstrapping,asitbetterac-countsforautocorrelationoveryearsanddistricts.Thelistofcovariatesthatwereexploredincludedrainfalllevels,fertility,birthspacing,maternaleducation,schoolattendanceamongteenagers,femaleheadshipofhouseholds,meanhouseholdsize, household sanitation, prevalence of improved sourcesofcookingfuel,prevalenceof improvedwall type inhomes,electricity, immunization coverage, and coverageofmalariaandmaternalandchildhealthinterventionsdescribedinthe

main text of this report. Covariates that were not includedbecauseof lackofdata availability include coverageofma-lariatreatmentforchildrenwithfever,coverageofantibiotictreatment for childrenwithpneumonia, coverageof oral re-hydration treatment for children with diarrhea, coverage ofpediatricHIV treatment,qualityofdistrict healthofficeman-agement, district health expenditures and health personnel,accesstohealthfacilities,malariatransmission intensityovertimeandbydistrict,andnutritionalinterventions.

The MCPA research team found that it was statisticallyimpossible to tease out the impact of malaria control in-terventions from other interventions that also experiencedlargegains incoverageduring the2000s. Instead,principalcomponentanalysis(PCA)wasusedtobundletheserapidlyscaled-up interventionsmalaria control, exclusive breast-feeding,facilitiesofferingPMTCTperpopulationunder1yearold, and coverage of the pentavalent vaccineinto a com-positeindicator.Thefinalmodelestimatesthejointeffectoftheseinterventionsonunder-5mortality: ln(q) = 0 + 1Scaled + 2SES + 3Und + 4SES * Scaled + 5SES * Und + 6ANC1 + 7DPT3 + 8Meas + 9Year + k[ ] +

The final model was a linear model with bootstrapping,whereforeachdistrict ,provincek,andyear i, ln(q) isthenatural logarithm of the under-5mortality rate, 0 is the in-tercept, Scaled is the composite indicator for rapidly scaledup interventions,andSES is thecompositemeasure fornon-health factors. Und is the proportion of children who areunderweight,SES * Scaled isan interactionbetween thenon-healthfactorcompositemeasureandthecompositeindicatorforrapidlyscaledupinterventions,SES * Undisaninteractionbetween the non-health factor compositemeasure and theproportion of children who are underweight, ANC1 is cov-erageofoneantenatal care visit,DPT3 is coverageof threedosesofDPT,Meas iscoverageofonedoseof themeaslesvaccine,Yearisthecorrespondingyear,k[ j]isarandomeffectonprovincektowhichj belongs,and

istheerrorterm.

Annex 1. Overview of the MCPA analytical approach and methods

1 5

District profiles Trackingtrendsinchildhealthoutcomesandinterventioncoverageatthedistrictlevelprovidestimely,useful,andactionableinformationtonationalandlocalpolicymakersinZambia.

Thedistrictprofilesareorderedalphabeticallywithineachprovince.Eachprofileprovidesachildhealthbarometerfor2010,whichcomparesagivendistrictsperformanceonkeychildhealthoutcomesandinterventionstothenationalaverageandtherangeobservedacrossdistricts.Further,eachprofiledetailstrendsobservedforeachgroupofinterventions:malariainterventions,immunizations,andothermaternalandchildhealthinterventions.

Thesedistrictprofilesaimtoprovideafoundationfromwhich localhealthofficialscanassesstheirdistrictschildhealthstatusandthentargethigh-priorityareasforimprovement.IndividualprofilescanbedownloadedfromIHMEsGlobalHealthDataExchange:http://ghdx.healthmetricsandevaluation.org/.

1 7

Central province

1 8

KEY

Allcause under5 mortality

40

120

200

280

360

1990 1995 2000 2005 2010

Childhood underweight

0

20

40

60

80

100

1990 1995 2000 2005 2010


40

120

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360

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

From1990to2010,Chibomborecordedasignificantreduc-tion in all-cause under-5mortality, dropping 37% from 149deathsper1,000livebirthsin1990(95%CI:116,190)to94in2010(95%CI:69,126).In2010,thedistrictsunder-5mortalitywasmuchlowerthanthenationalaverageof109deathsper1,000livebirths(95%CI:104,116)andwasamongthelowestinZambiaforthatyear.

Theproportionofchildrenwhowereunderweightsteadilyincreasedfrom11%in1990(95%CI:6%,19%)to19%intheearly2000s.Levelsofunderweightremainedat19%through2003,afterwhichprevalencedeclinedto14%in2010(95%CI:10%,18%),equalingthenationalaverageforthatyear.

CHILD HEALTH OUTCOMES

SUMMARYChibombosubstantially reducedall-causeunder-5mortalitybetween1990and2010,bringingitsmortalitylevelsamongthe lowest in Zambia. Childhood underweight, however, in-creasedduringthe1990sbeforedeclining.Prioritizingwaysto further accelerate gains for child health outcomes, espe-ciallyunderweight,shouldbeconsidered.

Several interventions, including IPTp2, the pentavalentvaccine, and exclusive breastfeeding, were scaled up toor above the national averageby 2010.After slight dips incoverage,BCGandmeaslesimmunizationroseabovethena-tionalaveragesin2010.

However, amidst these gains, some worrisome trendswere identified and warrant further attention. Chibombosscale-up of ITNs and IRS laggedbehind the national trend,andpoliocoveragedeclinedinrecentyears.Skilledbirthat-tendance stayedquite low, and alarmingly,ANC4droppedsharplyfromhighlevelsofcoverageintheearly1990s.

In2010,Chibombogenerallymetorexceedednationallevelsforimmunizations,andequaledorfellbelowformalariainterventions.Formaternalandchildhealthinterventions,thedistricthadamoremixedperformance. Incomparisonwiththenationalaverage,Chibomboshowedmuchlowerlevelsofmortalityandsimilarlevelsofunderweight.

Dea

thsper1,000

livebirths

Percen

t(%)

Nationaltrend Chibombo Uncertaintyinterval

Rangeobserved acrossdistricts

Nationalaverage

Chibombo

Deat

hs p

er 1

,000

live

birth

s

60

80

100

120

140

160

CHILD HEALTHOUTCOMES

Childhoodunderweight

Under-5mortality

Malaria Immunizations Maternal & child health

INTERVENTIONS

IPTp(2 doses)

Exclusivebreastfeeding

Antenatalcare

(4 visits)

ITNownership

ITN useunder-5

Indoor residualspraying

BCG PentavalentMeasles Polio Skilledbirth

attendance

0

20

40

60

80

100Pe

rcen

t (%

)

0

20

40

60

80

100

Perc

ent (

%)

Note:Levelsofchildhealthoutcomesandinterventioncoveragearefor2010.Betterperformanceisreflectedbylowerlevelsofchildhealthoutcomes (orange)andhigherlevelsofinterventioncoverage(green).

Chibombo

1 9

ITNownership remainedbelow10%until2004,afterwhichcoverageincreasedto56%in2009(95%CI:51%,60%)andremainedat56%through2010.This levelof ITNownershipwaslowerthanthenationalaverageof62%for2010.

ITNusebychildrenunder5yearsoldroseto44%in2010(95%CI: 38%, 50%), which was lower than the national av-erageof51%.ThedifferencebetweenITNownershipanduse(12percentagepoints)inChibombowascomparabletowhatwasobservedatthenationallevelfor2010.

Chibombo formally implemented IRS activities in 2010,andreached16%ofhouseholdsthatyear(95%CI:11%,22%).ThiswasamongthelowestlevelsofIRScoverageacrossthe54districtsthathadIRSby2010.

Theproportionofpregnantwomenwho received IPTp2remainedbelow10%until 2001, afterwhich coverage roseto70%in2008(95%CI:60%,80%).IPTp2coverageslippedto68%in2010(95%CI:56%,78%),equalingthenationalav-erageforthatyear.

BCGcoveragedeclinedfrom99%intheearly1990sto94%intheearly2000s,butincreasedto97%in2009(95%CI:94%,98%)andremainedat97%through2010.This levelofBCGcoverage was higher than the national average of 95% for2010.

Measles immunization decreased from 98% in the early1990sto91%inthelate1990s,afterwhichcoverageclimbedto 99% in 2007 (95% CI: 98%, 99%) and remained at 99%through 2010. This level of measles coverage was slightlyhigherthanthenationalaverageof98%for2010.

Coverage of polio immunization dropped from 95% in1990(95%CI:91%,98%)to70%in1997(95%CI:65%,75%),but then rose to 90% in themid-2000s. Polio coverage de-clinedsoonafter,decreasing to79% in2010 (95%CI:62%,91%),slightlybelowthenationalaverageof81%.

Afterthepentavalentvaccinewasformally introducedinChibomboin2005,coverageincreasedto51%in2006(95%CI:44%,57%)and69%in2010(95%CI:55%,82%),slightlyexceedingthenationalaverageof67%.

ANC4coveragesteadily fell from84%in1990(95%CI:74%,92%) to38% in2010 (95%CI:11%,74%),whichwascompa-rabletothenationalaverageof37%thatyear.ThefindingthatChibombos levelsofcoveragefellmorethan45percentagepointsduringthistimeiscauseforconcern.

Skilled birth attendance decreased from 40% in 1990(95%CI:26%,55%)to21%intheearly2000s,afterwhichcov-erageslowlyroseto30%in2010(95%CI:7%,66%).ThislevelofSBAcoveragewasbelowthenationalaverageof55%for

2010,andChibombogenerallyhadlowerSBAcoveragethanthenationalaveragefrom1990to2010.

Theproportionofchildrenwhowereexclusivelybreastfedremained below 20% until 1998, after which coverageclimbed to 67% in 2004 (95%CI: 60%, 73%).Gains in cov-eragestalleduntil2008,afterwhichexclusivebreastfeedingincreasedto91%in2010(95%CI:83%,96%),farexceedingthenationalaverageof80%.

MALARIA INTERVENTIONS

IMMUNIZATIONS

MATERNAL AND CHILD HEALTH INTERVENTIONS

ITN ownership

0

20

40

60

80

100

1990 1995 2000 2005 2010

ITN use by children under 5

0

20

40

60

80

100

1990 1995 2000 2005 2010

Indoor residual spraying

0

20

40

60

80

100

1990 1995 2000 2005 2010

IPTp (2 doses)

0

20

40

60

80

100

1990 1995 2000 2005 2010

BCG immunization

0

20

40

60

80

100

1990 1995 2000 2005 2010

Measles immunization

0

20

40

60

80

100

1990 1995 2000 2005 2010

Polio immunization

0

20

40

60

80

100

1990 1995 2000 2005 2010

Pentavalent immunization

0

20

40

60

80

100

1990 1995 2000 2005 2010

Antenatal care (4 visits)

0

20

40

60

80

100

1990 1995 2000 2005 2010

Skilled birth attendance

0

20

40

60

80

100

1990 1995 2000 2005 2010

Exclusive breastfeeding

0

20

40

60

80

100

1990 1995 2000 2005 2010

2 0

KEY


40

120

200

280

360

1990 1995 2000 2005 2010


0

20

40

60

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100

1990 1995 2000 2005 2010


40

120

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280

360

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

From1990to2010,Kabwerecordedareductioninall-causeunder-5mortality,dropping33%from143deathsper1,000livebirthsin1990(95%CI:111,184)to96in2010(95%CI:69,132);however,thisdeclinewasnotstatisticallysignificant.In2010,thedistrictsunder-5mortalitywaslowerthanthena-tionalaverageof109deathsper1,000livebirths(95%CI:10,116).

The proportion of children who were underweight in-creasedfrom11%intheearly1990sto14%intheearly2000s,after which underweight slightly declined to 13% in 2003(95%CI:11%,16%)andremainedatthislevelthrough2010.Althoughchildhoodunderweightwascomparabletothena-tionalaverageof14%for2010,thedistrictsminimalprogressiscauseforconcern.


SUMMARYBetween1990and2010,Kabwereduceditsall-causeunder-5mortality,buttherelativemagnitudeofthedistrictsprogresswasfairlylow.Whilechildhoodunderweightwascomparableto the national average, Kabwe made minimal progress inreducing prevalence. Prioritizing ways to further accelerategainsforchildhealthoutcomesshouldbeconsidered.

Kabwe increased IPTp2 coverage to well above the na-tional average in 2010, and IRS coverage was among thehighest inZambiathatyear.Thedistrictmadenotableprog-ress in increasingcoverageof thepentavalent vaccine,andhighlevelsofBCGandmeaslesimmunizationweresustainedduring the 2000s. Exclusive breastfeeding rebounded fromdeclinesincoverageduringtheearly2000s.Skilledbirthat-

tendancesteadilyincreasedovertime,reachingsomeofthehighestlevelsofcoverageinthecountry.

However, amidst these gains, some troubling trendswereidentifiedandwarrantfurtherattention.Poliocoveragedeclinedinrecentyears,andalarmingly,ANC4coveragede-creasedsharplyfromveryhighlevelsduringthe1990s.

In 2010, Kabwe generally met or exceeded nationallevelsacrossinterventions,withthestarkexceptionofANC4coverage. In comparison with the national average, Kabweshowedlower levelsofmortalityandsimilar levelsofunder-weight.

Dea

thsper1,000

livebirths

Percen

t(%)

Nationaltrend Kabwe Uncertaintyinterval


Nationalaverage

Kabwe

Deat

hs p

er 1

,000

live

birth

s

60

80

100

120

140

160



Under-5mortality


INTERVENTIONS

IPTp(2 doses)


Antenatalcare

(4 visits)

ITNownership

ITN useunder-5



attendance

0

20

40

60

80

100Pe

rcen

t (%

)

0

20

40

60

80

100

Perc

ent (

%)

Note:Levelsofchildhealthoutcomesandinterventioncoveragearefor2010.Betterperformanceisreflectedbylowerlevelsofchildhealthoutcomes(orange)andhigherlevelsofinterventioncoverage(green).

Kabwe

2 1

ITNownership remainedbelow10%until2001,afterwhichcoverageincreasedto59%in2008(95%CI:55%,64%)butslippedto56%in2010(95%CI:50%,61%).ThislevelofITNownership was lower than the national average of 62% in2010.

ITNusebychildrenunder5yearsoldclimbedto48%in2010(95%CI:42%,55%),butremainedslightlylowerthanthenationalaverageof51%forthatyear.ThedifferencebetweenITN ownership and use (8 percentage points) was slightlylowerinKabwethanwhatwasobservedatthenationallevel(11percentagepoints)for2010.

Kabwe formally implemented IRS activities in 2003, andwasoneofthefirst15districts inZambiatorolloutIRS. IRScoveragepeakedat67% in2008 (95%CI:63%,71%), afterwhichcoveragedroppedto58%in2010(95%CI:52%,64%).Nonetheless,Kabwehadoneof thehighest levelsof IRS inZambiain2010.

Theproportionofpregnantwomenwho received IPTp2remainedbelow10%until2001,afterwhichcoveragerapidlyroseto2009at81%(95%CI:72%,88%)andwasmaintainedthrough2010.ThislevelofIPTp2coveragewasmuchhigherthanthenationalaverageof68%for2010.

BCGcoveragedeclinedfrom97%in1990(95%CI:94%,99%)to95%intheearlytomid-1990s,butincreasedto99%inthemid-2000s.Coverageslippedto96%in2010(95%CI:93%,98%),butremainedslightlyhigherthanthenationalaverageof95%.

Measlesimmunizationincreasedfrom82%in1990(95%CI:69%,91%)to98%in2003(95%CI:97%,99%),afterwhichcoveragewassustainedat98%through2010,equaling thenationalaverage.

Coverage of polio immunization sharply declined from93%in1990(95%CI:87%,96%)to76%in1997(95%CI:72%,80%). Polio coverage hovered just above 80% from 2000 to2008,afterwhichimmunizationratesdroppedto72%in2010(95%CI:57%,83%),fallingbelowthenationalaverageof81%.

Afterthepentavalentvaccinewasformally introducedinKabwein2005,coverageincreasedto53%in2006(95%CI:46%,60%)and68%in2010(95%CI:57%,79%),whichwascomparabletothenationalaverageof67%.

ANC4coverage increased from66% in1990 (95%CI: 53%,78%)to74%inthemid-1990s,butdroppedconsiderablyto23%in2010(95%CI:5%,53%),fallingbelowthenationalav-erageof37%.ThefindingthatKabweslevelsofcoveragefell50percentagepointssincethemid-1990sisworrisome.

Skilled birth attendance steadily increased from 48% in1990(95%CI:36%,61%)to86%in2007and2008,afterwhichcoverageslippedto83%in2010(95%CI:57%,96%).Despite

thisdecline,KabwesSBAcoveragewasamongthehighestinZambiain2010.

Theproportionofchildrenwhowereexclusivelybreastfedremainedbelow20%until1995,afterwhichcoveragerapidlyclimbedto78%in2002(95%CI:73%,82%).Exclusivebreast-feedingthendeclined,droppingto60%in2006(95%CI:53%,67%).Coveragereboundedto77%in2010(95%CI:66%,85%),butremainedslightlylowerthanthenationalaverageof80%.


IMMUNIZATIONS


ITN ownership

0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

IPTp (2 doses)

0

20

40

60

80

100

1990 1995 2000 2005 2010

BCG immunization

0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

Polio immunization

0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

2 2

KEY


40

120

200

280

360

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


40

120

200

280

360

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

From 1990 to 2010, Kapiri-Mposhi recorded a reduction inall-causeunder-5mortality, dropping26% from151deathsper1,000livebirthsin1990(95%CI:118,193)to112in2010(95%CI:83,149);however, thisdeclinewasnotstatisticallysignificant.In2010,thedistrictsunder-5mortalitywasslightlyhigherthanthenationalaverageof109deathsper1,000livebirths(95%CI:104,116).

The proportion of children who were underweight in-creasedfrom9%in1990(95%CI:4%,18%)toahighof18%in1999(95%CI:15%,21%),butthendeclinedto9%in2009(95%CI: 7%,12%) and remainedat 9% through2010.Thislevel of underweight wasmuch lower than the national av-erageof14%in2010andamongthelowestinZambia.


SUMMARYKapiri-Mposhi reduced its all-cause under-5 mortality be-tween 1990 and 2010, but the relative magnitude of thedistrictsprogresswaslow.Afteraperiodofincreasinglevelsofunderweight,thedistrictreduceditsprevalencetosomeofthelowestlevelsinZambia.Prioritizingwaystofurtheraccel-eratedeclinesinchildhealthoutcomes,especiallyforunder-5mortality,shouldbeconsidered.

The district successfully scaled up several interventions,rangingfromIPTp2to thepentavalentvaccine, tocoveragelevels equaling or exceeding the national average in 2010.High levels of measles coverage were maintained after in-creasesinthe1990s,andpoliocoveragerosetoamongthehighestinZambiain2010.

However,amidstthesesuccesses,sometroublingtrendswereidentifiedandwarrantfurtherattention.BCGcoveragefellbelow thenationalaverage in2010,and ITNownershipwas among the lowest levels in Zambia. The district expe-rienced substantial declines in ANC4 coverage and skilledbirthattendance.

In2010,Kapiri-Mposhigenerallymetorexceedednationallevels for immunizations, andequaledor fellbelownationallevelsformaternalandchildhealthinterventions.Formalariainterventions, thedistricthadamoremixedperformance. Incomparisonwiththenationalaverage,Kapiri-Mposhishowedslightlyhigherlevelsofmortalityandmuchlowerlevelsofun-derweight.

Dea

thsper1,000

livebirths

Percen

t(%)

Nationaltrend Kapiri-Mposhi Uncertaintyinterval


Nationalaverage

Kapiri-Mposhi

Deat

hs p

er 1

,000

live

birth

s

60

80

100

120

140

160



Under-5mortality


INTERVENTIONS

IPTp(2 doses)


Antenatalcare

(4 visits)

ITNownership

ITN useunder-5



attendance

0

20

40

60

80

100Pe

rcen

t (%

)

0

20

40

60

80

100

Perc

ent (

%)


Kapiri-Mposhi

2 3

ITNownership remainedbelow10%until2003,afterwhichcoverage increased to 54% in 2010 (95% CI: 49%, 59%),fallingwellbelowthenationalaverageof62%andamongthelowestinZambiathatyear.

ITNusebychildrenunder5yearsoldclimbedto57%in2009(95%CI:52%,62%),butslippedto55%in2010(95%CI:49%,61%).ThislevelofITNusewasslightlyhigherthanthenationalaverageof51%for2010.ITNusewasslightlyhigherthanITNownershipinKapiri-Mposhifor2010,whichsuggeststhatnetusebychildrenunder5maybehighamonghouse-

holdsthathaveITNs.Kapiri-MposhiformallyimplementedIRSactivitiesin2008

andreached19%ofhouseholdsin2010(95%CI:16%,23%).Thisscale-upof IRSwasamongthelowestamongtheotherdistrictsthatalsobeganIRSin2008.

Theproportionofpregnantwomenwho received IPTp2remainedbelow10%until2003,afterwhichcoveragerapidlyincreased to 70% in 2010 (95% CI: 56%, 81%), slightly ex-ceedingthenationalaverageof68%.

BCGcoveragedeclinedfrom93%in1990(95%CI:86%,97%)to 89% during the mid- to late 1990s. Coverage hoveredaround90%inthe2000s,risingto91%in2010(95%CI:85%,95%),whichwaslowerthanthenationalaverageof95%.

Measles immunization remained below 80% until 1998,afterwhichcoveragesteadilyclimbedto98%in2008(95%CI:95%,99%)andremainedatthislevelthrough2010,equalingthenationalaverageforthatyear.

Risingfromalowof64%in1990(95%CI:48%,79%),cov-erage of polio immunization largely hovered around 70%

until2006,afterwhichpoliocoverageclimbedto94%in2010(95%CI:87%,98%)andemergedasoneofthehighestlevelsinZambia for thatyear.Thesegainsareparticularlynotablegiventhatthedistrictspoliocoveragewasconsistentlylowerthanthenationalaverageuntilthemid-2000s.

Afterthepentavalentvaccinewasformally introducedinKapiri-Mposhi in 2005, coverage increased to 47% in 2006(95%CI:40%,55%)and78%in2010(95%CI:68%,88%),farexceedingthenationalaverageof67%.

ANC4coveragegraduallydeclined from52% in1990 (95%CI:34%,68%)to36%in2010(95%CI:9%,72%).WhilethedistrictsANC4coveragewascomparabletothenationalav-erageof37%in2010,itslevelsofANC4remainedquitelow.

Skilled birth attendance decreased from 48% in 1990(95%CI:31%,64%)toalowof22%in2010(95%CI:5%,55%),fallingbelowthenationalaverageof55%.Thistrendofsteadydeclineiscauseforconcern,directlycontrastingwithgradual

increasesinSBAcoverageobservedatthenationallevel.Theproportionofchildrenwhowereexclusivelybreastfed

remained below 20% until 1998, after which coverage rap-idly increasedto62%in2004(95%CI:55%,69%).Gains incoveragestalled through2007,butexclusivebreastfeedingclimbedto80%in2010(95%CI:69%,88%),equalingthena-tionalaverage.


IMMUNIZATIONS


ITN ownership

0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

IPTp (2 doses)

0

20

40

60

80

100

1990 1995 2000 2005 2010

BCG immunization

0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

Polio immunization

0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

2 4

KEY


40

120

200

280

360

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


40

120

200

280

360

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

From1990to2010,Mkushirecordedasignificantreductioninall-causeunder-5mortality,dropping34%from169deathsper1,000livebirthsin1990(95%CI:132,213)to111in2010(95%CI:82,149).In2010,thedistrictsunder-5mortalitywascomparabletothenationalaverageof109deathsper1,000livebirths(95%CI:104,116).

The proportion of children who were underweight in-creasedfrom17%intheearly1990stoahighof21%in1999(95%CI:17%,25%),butthendecreasedto13%in2010(95%CI:10%,18%).Thislevelofunderweightwascomparabletothenationalaverageof14%in2010.


SUMMARYMkushisubstantiallyreducedall-causeunder-5mortalityfrom1990to2010.Childhoodunderweight increasedduringthe1990sbeforedecreasinginrecentyears.Prioritizingwaystofurtheraccelerateratesofprogressinchildhealthoutcomesshouldbeconsidered.

IPTp2 coverage reached some of the highest levels inZambia in 2010, and ITN coverage consistently exceededthenationalaverage.Pentavalentcoveragewashigher thanthe national average in 2010, and exclusive breastfeedingclimbedtosomeofthehighestlevelsinthecountry.BCGandmeaslescoverageremainedhighduringthe2000s,andpoliocoveragewascomparabletothenationalaveragein2010.

However, amidst these gains, some worrisome trendswereidentifiedandwarrantfurtherattention.ANC4coveragedeclined after a period of steady gains during the 1990s.Skilledbirthattendancegraduallyincreasedinthe1990s,butsharplydroppedtoverylowlevelsin2010.SBAcoverageinMkushiwasamongthelowestinZambiafor2010.

In2010,Mkushigenerallymetorexceedednationallevelsacrossinterventions,withtheclearexceptionofskilledbirthattendance.Incomparisonwiththenationalaverage,Mkushishowedsimilarlevelsofmortalityandunderweight.

Dea

thsper1,000

livebirths

Percen

t(%)

Nationaltrend Mkushi Uncertaintyinterval


Nationalaverage

Mkushi

Deat

hs p

er 1

,000

live

birth

s

60

80

100

120

140

160



Under-5mortality


INTERVENTIONS

IPTp(2 doses)


Antenatalcare

(4 visits)

ITNownership

ITN useunder-5



attendance

0

20

40

60

80

100Pe

rcen

t (%

)

0

20

40

60

80

100

Perc

ent (

%)

Note:Levelsofchildhealthoutcomesandinterventioncoveragearefor2010.Betterperformanceisreflectedbylowerlevelsofchildhealthoutcomes (orange)andhigherlevelsofinterventioncoverage(green).IRScoveragewasnotincludedbecauseMkushistartedIRSafter2010.

Mkushi

2 5

ITNownership remainedbelow10%until2001,afterwhichITNownershiprapidlyincreasedto67%in2008(95%CI:60%,73%).Ownershipslippedto65%in2010(95%CI:57%,71%),remainingslightlyabovethenationalaverageof62%.

ITNusebychildrenunder5yearsoldquicklyroseto64%in2008(95%CI:56%,72%),butdeclinedto58%in2010(95%CI:48%,67%).ThislevelofITNuseremainedhigherthanthenationalaverageof51%for2010.ThedifferencebetweenITNownershipanduse(7percentagepoints)waslowerinMkushi

thanwhatwasobservedatthenationallevel(11percentagepoints)for2010.

IRScoveragetrendsarenotincludedbecauseMkushididnotbeginformalIRSactivitiesuntilafter2010.

Theproportionofpregnantwomenwho received IPTp2remainedbelow10%until2002,afterwhichcoveragerapidlyclimbed to92% in2010 (95%CI:85%,96%), farexceedingthenationalaverageof68%andrisingtoamongthehighestlevelsinZambia.

BCG coverage hovered around 90% until the mid-2000s,afterwhichcoverageclimbedto99%in2010(95%CI:98%,100%),whichwasamongthehighestlevelsofBCGcoverageinZambiaforthatyear.

Measles immunization steadily increased from 74% in1990(95%CI:60%,84%)to98%in2008(95%CI:96%,99%).Thislevelofcoveragewasmaintainedthrough2010,equalingthenationalaverage.

Coverageofpolioimmunizationgraduallyrosefrom69%in 1990 (95%CI: 54%, 81%) to 85% in 2007 (95%CI: 79%,89%),whichwasmaintainedthrough2010.Thislevelofpoliocoveragewasslightlyhigherthanthenationalaverageof81%for 2010.

Afterthepentavalentvaccinewasformally introducedinMkushiin2005,coverageincreasedto47%in2006(95%CI:39%,55%)and77%in2010(95%CI:63%,87%),risingabovethenationalaverageof67%.

ANC4coveragegraduallyincreasedfrom45%in1990(95%CI:29%,60%) to66% in theearly2000s,but thendeclinedto52%in2010(95%CI:14%,86%).WhileANC4coverageinMkushistayedabovethenationalaverageof37%in2010,itslevelsremainedlowerthanoptimal.

Skilled birth attendance slightly increased from 24% intheearly1990sto30%inthe late1990s,butthendroppedsharplyto4%in2010(95%CI:0%,16%), fallingwellbelow

thenationalaverageof55%andamongthelowestinZambiafor 2010. Mkushis consistently low level of SBA coverage,pairedwithitsrecentdecline,iscauseforconcern.

Theproportionofchildrenwhowereexclusivelybreastfedremainedbelow20%until1997,afterwhichcoveragerapidlyincreasedto95%in2010(95%CI:91%,98%),risingamongthehighestlevelsinZambiaforthatyear.


IMMUNIZATIONS


ITN ownership

0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

IPTp (2 doses)

0

20

40

60

80

100

1990 1995 2000 2005 2010

BCG immunization

0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

Polio immunization

0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

2 6

KEY


40

120

200

280

360

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


40

120

200

280

360

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

From 1990 to 2010, Mumbwa recorded a reduction in all-causeunder-5mortality,dropping23%from140deathsper1,000 livebirths in1990 (95%CI: 109, 178) to108 in2010(95%CI: 81,144); however, this declinewas not statisticallysignificant. In2010, thedistrictsunder-5mortalitywascom-parabletothenationalaverageof109deathsper1,000livebirths (95%CI:104,116). It is important tonotethatbefore

2000,theunder-5mortalityinMumbwawasgenerallylowerthanthenationaltrend.

Theproportionof childrenwhowereunderweightgrad-uallydecreasedfrom15%inthe1990sto12%in2005(95%CI:10%,15%).Underweightremainedat12%through2010,whichwasslightlylowerthanthenationalaverageof14%forthatyear.


SUMMARYMumbwareducedall-causeunder-5mortalityandchildhoodunderweightfrom1990to2010,buttherelativemagnitudeofthedistrictsprogresswasfairlylow.Prioritizingwaystoaccel-erategainsforchildhealthoutcomesshouldbeconsidered.

Thedistrictrapidlyscaledupcoverageofthepentavalentvaccineandexclusivebreastfeeding,exceedingthenationalaverage for each in 2010.Mumbwa recorded some of thehighest levels of polio coverage in the country, and experi-encedgradualgainsinskilledbirthattendance.

However,amidstthesegains,sometroublingtrendswereidentifiedandwarrant furtherattention.Mumbwasawsmalldeclinesinmeaslescoverageinthelate2000s.Whilethedis-

trictwasabletoquicklyscaleupcoverageofITNsandIPTp2,coveragelargelyfellbelowthenationalaveragein2010.Fur-ther, ITNownershipandusedropped toamong the lowestlevels in Zambia in 2010. Like inmany districts, ANC4 cov-eragedecreasedafteraperiodofincreasinglevelsduringthe1990s.

In 2010, Mumbwa generally met or exceeded nationallevels for immunizations and maternal and child healthinterventions,butfellbelownationalaveragesformalariainter- ventions.Incomparisonwiththenationalaverage,Mumbwashowedsimilarlevelsofmortalityandslightlylowerlevelsofunderweight.

Dea

thsper1,000

livebirths

Percen

t(%)

Nationaltrend Mumbwa Uncertaintyinterval


Nationalaverage

Mumbwa

Deat

hs p

er 1

,000

live

birth

s

60

80

100

120

140

160



Under-5mortality


INTERVENTIONS

IPTp(2 doses)


Antenatalcare

(4 visits)

ITNownership

ITN useunder-5



attendance

0

20

40

60

80

100Pe

rcen

t (%

)

0

20

40

60

80

100

Perc

ent (

%)


Mumbwa

2 7

ITNownership remainedbelow10%until2002,afterwhichcoverage quickly increased to 50% in 2008 (95% CI: 44%,56%).Ownershipslippedto47%in2010(95%CI:41%,53%),fallingwellbelowthenationalaverageof62%andamongthelowestlevelsinZambia.

ITNusebychildrenunder5yearsoldsteadilyroseto35%in2010(95%CI:28%,42%),butthislevelofITNuseremainedwellbelowthenationalaverageof51%andwasamongthelowestinthecountry.ThedifferencebetweenITNownershipanduse(12percentagepoints)inMumbwawascomparable

towhatwasobservedatthenationallevelfor2010.MumbwaformallyimplementedIRSactivitiesin2008,and

reached39%ofhouseholdsin2010(95%CI:34%,45%).Thisscale-upofIRSwasaboutaverageamongtheotherdistrictsthatalsobeganIRSin2008.

Theproportionofpregnantwomenwho received IPTp2remained below 10% until 2001, after which coverage rap-idlyroseto65%in2008(95%CI:51%,78%).IPTp2coverageslippedto62%in2010(95%CI:49%,75%),whichwaslowerthanthenationalaverageof68%.

BCGcoveragedecreasedfrom97%intheearly1990sto93%inthelate1990s,butincreasedto98%in2009(95%CI:96%,99%)andremainedat98%through2010.This levelofBCGimmunizationexceededthenationalaverageof95%for2010.

Measles immunization increased from a low of 79% in1990(95%CI:65%,89%)to98%in2002(95%CI:96%,98%).Coverageremainedat98%through2003,butdecreasedto96%in2010(95%CI:88%,99%),fallingslightlybelowthena-tionalaverageof98%.

Coverage of polio immunization climbed from 68% in1990(95%CI:52%,82%)to84%inthemid-1990s.Poliocov-eragehoveredaround80%until2004,afterwhichcoveragesteadilyincreasedto98%in2010(95%CI:95%,100%),risingtoamongthehighestinZambiaforthatyear.

Afterthepentavalentvaccinewasformally introducedinMumbwain2005,coverage increasedto61%in2006(95%CI: 54%, 69%) and 80% in 2010 (95% CI: 66%, 89%), ex-ceedingthenationalaverageof67%.

ANC4coveragehoveredaround60%duringtheearlytomid-1990sand then increased to69% in theearly2000s.ANC4thendecreasedto56%in2010(95%CI:19%,88%).WhilethislevelofANC4coveragewasstillhigherthanthenationalav-erageof37%for2010,itremainedlowerthanoptimal.

Skilled birth attendance gradually climbed from 33% in1990(95%CI:20%,47%)to61%in2010(95%CI:25%,90%),

whichwasslightlyhigherthanthenationalaverageof55%forthatyear.

Theproportionofchildrenwhowereexclusivelybreastfedremainedbelow20%until1999,afterwhichcoverageroseto60%in2003(95%CI:53%,67%).Gains incoveragesloweduntil2007andthenquicklyclimbedto91%in2010(95%CI:82%,95%),farexceedingthenationalaverageof80%.


IMMUNIZATIONS


ITN ownership

0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

IPTp (2 doses)

0

20

40

60

80

100

1990 1995 2000 2005 2010

BCG immunization

0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

Polio immunization

0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

2 8

KEY


40

120

200

280

360

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


40

120

200

280

360

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

From1990to2010,Serenjerecordedasignificantreductioninall-causeunder-5mortality,dropping43%from188deathsper1,000livebirthsin1990(95%CI:147,236)to107in2010(95%CI:78,145).In2010,thedistrictsunder-5mortalitywascomparabletothenationalaverageof109deathsper1,000livebirths(95%CI:104,116).

Theproportionofchildrenwhowereunderweightsteadilydeclinedfrom30%in1990(95%CI:20%,43%)to18%in2009(95% CI: 14%, 23%), which was maintained through 2010.Despitethisprogress,Serenjesprevalenceofchildhoodun-derweightremainedhigherthanthenationalaverageof14%for 2010.


SUMMARYSerenjerecordedsubstantialreductionsinall-causeunder-5mortalityandchildhoodunderweightfrom1990to2010,butits levelsofunderweight remainedhigher than thenationalaveragein2010.Prioritizingwaystoaccelerategainsforchildhealthoutcomesshouldbeconsidered.

MalariainterventioncoveragequicklyincreasedinSerenjeandwassustainedthrough2010.SerenjeexpandedcoverageofBCGandmeaslesimmunizationafterdeclinesintheearlytomid-2000s,andthedistrictsawsubstantialgainsinskilledbirthattendanceafteryearsofextremelylowcoverage.Exclu-sivebreastfeedingalsowashigherthanthenationalaveragein2010.

At thesame time,Serenjemarginally scaledup thepen-

tavalent vaccine, and polio coverage steeply fell in recentyears.In2010,thedistrictrecordedsomeofthelowestlevelsof coverage in Zambia for these two immunizations. ANC4coverage dramatically decreased to among the lowestlevelsinthecountry.WithitslowlevelsofANC4inparticular,Serenjewill likelybenefit from targeting these interventionsforimprovement.

In2010, Serenjegenerally equaledorexceeded thena-tionallevelsformalariainterventionsandmaternalandchildhealthinterventions(excludingANC4).Serenjesperformanceacross immunizations wasmore varied. In comparison withthe national average, Serenje showed similar levels ofmor-talityandhigherlevelsofunderweight.

Dea

thsper1,000

livebirths

Percen

t(%)

Nationaltrend Serenje Uncertaintyinterval


Nationalaverage

Serenje

Deat

hs p

er 1

,000

live

birth

s

60

80

100

120

140

160



Under-5mortality


INTERVENTIONS

IPTp(2 doses)


Antenatalcare

(4 visits)

ITNownership

ITN useunder-5



attendance

0

20

40

60

80

100Pe

rcen

t (%

)

0

20

40

60

80

100

Perc

ent (

%)

Note:Levelsofchildhealthoutcomesandinterventioncoveragearefor2010.Betterperformanceisreflectedbylowerlevelsofchildhealthoutcomes (orange)andhigherlevelsofinterventioncoverage(green).IRScoveragewasnotincludedbecauseSerenjestartedIRSafter2010.

Serenje

2 9

ITNownership remainedbelow10%until2003,afterwhichcoverage rapidly rose to 65% in 2010 (95%CI: 58%, 72%),slightlyexceedingthenationalaverageof62%.

ITNusebychildrenunder5yearsoldquickly increasedto51%in2010(95%CI:42%,58%),equalingthenationalav-erage for that year. The difference between ITN ownershipanduse(14percentagepoints)wasslightlyhigherinSerenjethanwhatwasobservedatthenationallevel(11percentage

points)for2010.IRScoveragetrendsarenotincludedbecauseSerenjedid

notbeginformalIRSactivitiesuntilafter2010.Theproportionofpregnantwomenwho received IPTp2

remained below 10% until 2003, after which coverage rap-idlyroseto69%in2009(95%CI:56%,79%).IPTp2coverageslippedto68%in2010(95%CI:54%,79%),equalingthena-tionalaveragefor2010.

BCG coverage increased from 69% in 1990 (95% CI: 54%,81%)to95%inthemid-1990s,butfellto90%duringthemid-2000s.Coverage rebounded to95% in2010 (95%CI: 89%,98%),equalingthenationalaverageforthatyear.

Measlesimmunizationquicklyrosefrom56%in1990(95%CI:40%,73%)to92%duringthemid-tolate1990s.Measlescoverage dipped below 90% during themid-2000s beforesteadily rising to99% in2010 (95%CI:96%,100%),slightlyexceedingthenationalaverageof98%forthatyear.

After rising from 67% in 1990 (95% CI: 51%, 80%), cov-erageofpolioimmunizationhoveredaround77%untilrising

to79%inthelate1990s.Poliocoveragethensteadilydeclined,droppingto46%in2010(95%CI:28%,66%)andfallingwellbelow the national average of 81%.This level of polio cov-eragewasamongthelowestinZambiafor2010.

Afterthepentavalentvaccinewasformally introducedinSerenjein2005,coveragehoveredaround40%through2009,risingslightly to45%in2010 (95%CI:29%,63%).Serenjeslevelofpentavalentcoveragewaswellbelowthenationalav-erageof67%for2010,andwasamongthelowestinZambia.Thedistrictsminimal scale-upof thepentavalent vaccine iscause for concern.

ANC4 coverage increased from38% in 1990 (95%CI: 26%,52%)to67%in1998(95%CI:49%,81%),butsteadilydeclinedthereafter,droppingto14%in2010(95%CI:2%,41%)andfallingbelowthenationalaverageof37%.Alarmingly,Seren-jesANC4coveragewasamongthelowestinZambiafor2010.

Skilledbirthattendancedeclinedfrom30%in1990(95%CI:18%,43%)to13%inthe late1990s,butsteadilyroseto66%in2010(95%CI:28%,92%),whichwashigherthanthenational averageof55% for that year. Serenjesprogress in

improvingitsSBAcoverageisnotablegiventhatthedistrictconsistently recorded levelsof coveragewell below thena-tionalaverageuntilthelate2000s.

Theproportionofchildrenwhowereexclusivelybreastfedremainedbelow20%until1999,afterwhichcoveragerapidlyrose to 70% in 2003 (95% CI: 63%, 76%). Exclusive breast-feedingcoverageremainedaround70%until2007,climbingto 86% in 2010 (95%CI: 77%, 93%) and exceeding the na-tionalaverageof80%.


IMMUNIZATIONS


ITN ownership

0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

IPTp (2 doses)

0

20

40

60

80

100

1990 1995 2000 2005 2010

BCG immunization

0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

Polio immunization

0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

3 1

Copperbelt province

3 2

KEY


40

120

200

280

360

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010


40

120

200

280

360

1990 1995 2000 2005 2010


0

20

40

60

80

100

1990 1995 2000 2005 2010

From1990to2010,Chililabombwerecordedasmall reduc-tion in all-cause under-5 mortality, dropping 7% from 131deathsper1,000livebirthsin1990(95%CI:101,169)to122in 2010 (95%CI: 89, 165). This declinewas not statisticallysignificant.In2010,thedistrictsunder-5mortalitywasmuchhigherthanthenationalaverageof109deathsper1,000livebirths(95%CI:104,116).Thislackofprogressisworrisome

given that the districts levels of under-5mortality were farbelowthenationaltrendduringthe1990s.

The proportion of children who were underweight in-creasedfrom13%intheearly1990sto17%in1998(95%CI:13%,21%),and remainedat this level through2002.Under-weightthendeclinedto14%inthelate2000s,equalingthenational average for 2010.Overall, thedistrict showedmar-ginalprogressinreducingchildhoodunderweight.


SUMMARYChililabombwehadminimalreductionsinitsall-causeunder-5mortalityandchildhoodunderweightfrom1990to2010;fur-ther,thedistrictslevelsofunder-5mortalityremainedhigherthanthenationalaverage in2010.Prioritizingwaystoaccel-erategainsforchildhealthoutcomesshouldbeconsidered.

Thedistrictgenerallyincreasedandmaintainedcoverageof IRS and IPTp2, and rapidly scaled up the pentavalentvaccine.Chililabombwesustainedhighlevelsofmeaslescov-erageovertime,andbroughtupexclusivebreastfeedingafteraperiodofstalledgains.ThedistrictsBCGcoveragein2010wasamongthehighestinZambia.

However,amidstthesesuccesses,sometroublingtrendswere identified andwarrant further attention. ITN coverage

wasmuchlowerthanthenationalaverage,andpolio immu-nization fell to oneof the lowest levels in Zambia for 2010.ANC4coveragesteadilydeclinedtovery lowlevels in2010,andalarmingly,skilledbirthattendancefellfromhighlevelsofcoverageinthe1990s.

In 2010, Chililabombwe generally met or exceeded na-tional levels for immunizations (with theexceptionofpolio),but fell below for maternal and child health interventions.The district had a more mixed performance for malariainterventions. Incomparisonwith thenationalaverage,Chil-ilabombwe showed higher levels of mortality and similarlevelsofunderweight.

Dea

thsper1,000

livebirths

Percen

t(%)

Nationaltrend Chililabombwe Uncertaintyinterval


Nationalaverage

Chililabombwe

Deat

hs p

er 1

,000

live

birth

s

60

80

100

120

140

160



Under-5mortality


INTERVENTIONS

IPTp(2 doses)


Antenatalcare

(4 visits)

ITNownership

ITN useunder-5



attendance

0

20

40

60

80

100Pe

rcen

t (%

)

0

20

40

60

80

100

Perc

ent (

%)


Chililabombwe

3 3

ITNownership remainedbelow10%until2003,afterwhichcoverageincreasedto46%in2010(95%CI:36%,56%).ThislevelofITNownershipwaswellbelowthenationalaverageof62%for2010,andwasamongthelowestinZambia.

ITNusebychildrenunder5yearsoldroseto43%in2010(95%CI: 31%, 55%), which was lower than the national av-erageof51%.In2010,thedifferencebetweenITNownershipandITNusewasquitelow,whichsuggeststhatnetusebychil-drenunder5maybehighamonghouseholdsthathaveITNs.

ChililabombweformallyimplementedIRSactivitiesin2000,andwasoneofthefirst15districtsinZambiatorolloutIRS.IRScoveragepeakedat58%in2008(95%CI:53%,63%),slightlydecreasingto55%in2010(95%CI:47%,61%).

Theproportionofpregnantwomenwho received IPTp2remained below 10% until 2002, after which coverage rap-idlyroseto79%in2008(95%CI:65%,89%).IPTp2coverageslipped to 76% in 2010 (95%CI: 60%, 88%), but remainedabovethenationalaverageof68%.

Risingfrom97%intheearly1990s,BCGcoverageremainedat98%through2010,whichexceededthenationalaverageof95%andwasamongthehighestinthecountry.

Measles immunization declined from 98% in the early1990sto95%duringthelate1990s,butincreasedto99%in2007(95%CI:98%,99%)andremainedat99%through2010.Thislevelofcoveragewasslightlyhigherthanthenationalav-erageof98%for2010.

Coverage of polio immunization dropped from 98% in1990(95%CI:96%,99%)to81%inthemid-1990s,butclimbed

to94%in2002(95%CI:90%,96%).Poliocoveragethende-clinedsharply,droppingto48%in2010(95%CI:26%,72%),amongthelowestlevelsinZambia.Thisdecreaseiscauseforconcerngiven that thedistrict consistently recordedhigherlevelsofcoveragethanthenationaltrendpriorto2006.

Afterthepentavalentvaccinewasformally introducedinChililabombwe in2005,coverage increasedto40%in2007(95%CI:33%,47%)and75%in2010(95%CI:60%,87%),ex-ceedingthenationalaverageof67%.

ANC4 coverage dropped considerably from 90% in 1990(95%CI:80%,96%)to15%in2010(95%CI:2%,48%),fallingbelowthenationalaverageof37%for2010.ANC4dramati-callydecreasedthroughoutZambiafrom1990to2010,andthe finding that Chililabombwes levels of coverage fell 75percentagepointsduringthistimeistroubling.

After rising to 98% in themid-1990s, skilled birth atten-dancedecreasedto52%in2010(95%CI:12%,88%),whichwasslightlylowerthanthenationalaverageof55%.However,

this decline in SBA coverageduring the 2000s is cause forconcerngiven that its levelsof coveragehadpreviously ex-ceededthenationaltrendbyatleast40percentagepoints.

Theproportionofchildrenwhowereexclusivelybreastfedremainedbelow20%until1995,afterwhichcoverageroseto54% in2001 (95%CI:47%,62%).Gains incoveragestalleduntil2007,andexclusivebreastfeedingthenclimbedto77%in2010(95%CI:64%,87%).Thislevelofcoveragewasslightlylowerthanthenationalaverageof80%for2010.


IMMUNIZATIONS


ITN ownership

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1990 1995 2000 2005 2010


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1990 1995 2000 2005 2010

IPTp (2 doses)

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1990 1995 2000 2005 2010

BCG immunization

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1990 1995 2000 2005 2010


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1990 1995 2000 2005 2010

Polio immunization

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1990 1995 2000 2005 2010


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1990 1995 2000 2005 2010


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1990 1995 2000 20

Documents

Progress in Child Health Across Districts in Zambia