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

BMC Medicine

Emmanuela Gakidou⁶  Felix Masiye³  Marie Ng⁶  Peter Hangoma³  Peter Mulenga²  Matthew Schneider¹  Nancy Fullman⁶  Tom Achoki⁴  Laura Dwyer-Lindgren⁶  Katherine Ellicott Colson⁵ 

[1] USAID, Washington, DC, USA;Clinton Health Access Initiative, Lusaka, Zambia;Department of Economics, University of Zambia, Lusaka, Zambia;Ministry of Health of Botswana, Gaborone, Botswana;University of California, Berkeley (UC Berkeley), Berkeley, CA, USA;Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA

关键词: Zambia;    Subnational benchmarking;    Maternal and child health;    Inequalities;    Indicators;    Coverage;   

Others  :  1160635
DOI  :  10.1186/s12916-015-0308-5

 received in 2014-12-08, accepted in 2015-03-02,  发布年份 2015

【 摘 要 】

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.

【 授权许可】

   
2015 Colson et al.; licensee BioMed Central.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

【 参考文献 】

• [1]Sustainable Development Knowledge Platform. Open working group proposal for sustainable development goals. https://sustainabledevelopment.un.org/sdgsproposal.
• [2]O’Connell T, Rasanathan K, Chopra M: What does universal health coverage mean? Lancet 2014, 383:277-9.
• [3]Victora CG, Wagstaff A, Schellenberg JA, Gwatkin D, Claeson M, Habicht J-P: Applying an equity lens to child health and mortality: more of the same is not enough. Lancet 2003, 362:233-41.
• [4]Victora CG, Hanson K, Bryce J, Vaughan JP: Achieving universal coverage with health interventions. Lancet 2004, 364:1541-48.
• [5]Braveman P, Tarimo E. Social inequalities in health within countries: not only an issue for affluent nations. Soc Sci Med 1982. 2002;54:1621–35.
• [6]Barros AJ, Ronsmans C, Axelson H, Loaiza E, Bertoldi AD, França GV, et al.: Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries. Lancet 2012, 379:1225-33.
• [7]Hosseinpoor AR, Victora CG, Bergen N, Barros AJ, Boerma T: Towards universal health coverage: the role of within-country wealth-related inequality in 28 countries in sub-Saharan Africa. Bull World Health Organ 2011, 89:881-9.
• [8]Victora CG, Barros AJD, Axelson H, Bhutta ZA, Chopra M, França GVA, et al.: How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys. Lancet 2012, 380:1149-56.
• [9]Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al.: Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012, 380:2095-128.
• [10]World Health Organization. Making fair choices on the path to universal health coverage. Final report of the WHO Consultative Group on Equity and Universal Health Coverage. 2014. http://www.who.int/choice/documents/making_fair_choices/en/.
• [11]Bryce J, Arnold F, Blanc A, Hancioglu A, Newby H, Requejo J, et al.: Measuring coverage in MNCH: new findings, new strategies, and recommendations for action. PLoS Med 2013, 10:e1001423.
• [12]Barros AJD, Victora CG: Measuring coverage in MNCH: determining and interpreting inequalities in coverage of maternal, newborn, and child health interventions. PLoS Med 2013, 10:e1001390.
• [13]Countdown 2008 Equity Analysis Group, Boerma JT, Bryce J, Kinfu Y, Axelson H, Victora CG. Mind the gap: equity and trends in coverage of maternal, newborn, and child health services in 54 Countdown countries. Lancet. 2008;371:1259–67.
• [14]World Health Organization. Global Health Observatory. 2015. http://www.who.int/gho/en/.
• [15]The World Bank. World DataBank poverty and inequality database. 2015. http://databank.worldbank.org/data/home.aspx. Accessed Feb 7 2016.
• [16]Gwatkin DR: Health inequalities and the health of the poor: what do we know? What can we do? Bull World Health Organ 2000, 78:3-18.
• [17]Steketee RW, Eisele TP: Is the scale up of malaria intervention coverage also achieving equity? PLoS One 2009, 4:e8409.
• [18]Houweling TA, Ronsmans C, Campbell OM, Kunst AE: Huge poor-rich inequalities in maternity care: an international comparative study of maternity and child care in developing countries. Bull World Health Organ 2007, 85:745-54.
• [19]Wagstaff A: Socioeconomic inequalities in child mortality: comparisons across nine developing countries. Bull World Health Organ 2000, 78:19-29.
• [20]Makinen M, Waters H, Rauch M, Almagambetova N, Bitran R, Gilson L, et al.: Inequalities in health care use and expenditures: empirical data from eight developing countries and countries in transition. Bull World Health Organ 2000, 78:55-65.
• [21]Castro-Leal F, Dayton J, Demery L, Mehra K: Public spending on health care in Africa: do the poor benefit? Bull World Health Organ 2000, 78:66-74.
• [22]Van de Poel E, O’Donnell O, Van Doorslaer E. Are urban children really healthier? Evidence from 47 developing countries. Soc Sci Med 1982. 2007;65:1986–2003.
• [23]Bhutta ZA, Chopra M, Axelson H, Berman P, Boerma T, Bryce J, et al.: Countdown to 2015 decade report (2000–10): taking stock of maternal, newborn, and child survival. Lancet 2010, 375:2032-44.
• [24]Khadr Z: Monitoring socioeconomic inequity in maternal health indicators in Egypt: 1995–2005. Int J Equity Health 2009, 8:38.
• [25]Fotso J-C: Child health inequities in developing countries: differences across urban and rural areas. Int J Equity Health 2006, 5:9.
• [26]Fotso J-C: Urban–rural differentials in child malnutrition: trends and socioeconomic correlates in sub-Saharan Africa. Health Place 2007, 13:205-23.
• [27]Firestone R, Punpuing S, Peterson KE, Acevedo-Garcia D, Gortmaker SL. Child overweight and undernutrition in Thailand: is there an urban effect? Soc Sci Med 1982. 2011;72:1420–28.
• [28]National Health Performance Committee (NHPC): National Report on Health Sector Performance Indicators 2001. Australian Health Ministers’ Conference. Queensland Health, Brisbane; 2002.
• [29]Wolfson M, Podger A. Towards integrated and coherent health information systems for performance monitoring: the Canadian experience. In: OECD. Measuring up: Improving health system performance in OECD countries. Ottawa: OECD Publishing; 2002. p. 133–55.
• [30]Kulkarni SC, Levin-Rector A, Ezzati M, Murray CJ. Falling behind: life expectancy in US counties from 2000 to 2007 in an international context. Popul Health Metr. 2011;9:16.
• [31]US Burden of Disease Collaborators: The state of US health, 1990–2010: burden of diseases, injuries, and risk factors. JAMA J Am Med Assoc 2013, 310:591-608.
• [32]Dwyer-Lindgren L, Freedman G, Engell RE, Fleming TD, Lim SS, Murray CJ, et al.: Prevalence of physical activity and obesity in US counties, 2001–2011: a road map for action. Popul Health Metr 2013, 11:7.
• [33]Axelson H, Gerdtham U-G, Ekman B, Hoa DTP, Alfvén T: Inequalities in reproductive, maternal, newborn and child health in Vietnam: A retrospective study of survey data for 1997–2006. BMC Health Serv Res 2012, 12:456.
• [34]Meng Q, Xu L, Zhang Y, Qian J, Cai M, Xin Y, et al.: Trends in access to health services and financial protection in China between 2003 and 2011: a cross-sectional study. Lancet 2012, 379:805-14.
• [35]Singh PK: Trends in child immunization across geographical regions in India: focus on urban–rural and gender differentials. PLoS One 2013, 8:e73102.
• [36]Victora CG, Barros FC: Infant mortality due to perinatal causes in Brazil: trends, regional patterns and possible interventions. São Paulo Med J Rev Paul Med 2001, 119:33-42.
• [37]Morris SK, Awasthi S, Kumar R, Shet A, Khera A, Nakhaee F, et al.: Measles mortality in high and low burden districts of India: Estimates from a nationally representative study of over 12,000 child deaths. Vaccine 2013, 31:4655-61.
• [38]Jagnoor J, Suraweera W, Keay L, Ivers RQ, Thakur JS, Jha P, et al.: Unintentional injury mortality in India, 2005: Nationally representative mortality survey of 1.1 million homes. BMC Public Health 2012, 12:487.
• [39]Morris SK, Bassani DG, Awasthi S, Kumar R, Shet A, Suraweera W, et al.: Diarrhea, pneumonia, and infectious disease mortality in children aged 5 to 14 years in India. PLoS One 2011, 6:e20119.
• [40]The Million Death Study Collaborators: Causes of neonatal and child mortality in India: a nationally representative mortality survey Lancet 2010, 376:1853-60.
• [41]Nguyen K-H, Jimenez-Soto E, Morgan A, Morgan C, Hodge A: How does progress towards the MDG 4 affect inequalities between different subpopulations? Evidence from Nepal. J Epidemiol Community Health 2013, 67:311-9.
• [42]Paudel D, Shrestha IB, Siebeck M, Rehfuess EA: Neonatal health in Nepal: analysis of absolute and relative inequalities and impact of current efforts to reduce neonatal mortality. BMC Public Health 2013, 13:1239.
• [43]Countdown to 2015 Equity Working Group. Countdown Equity Country Profiles. 2010. http://www.countdown2015mnch.org/country-profiles.
• [44]Van Eijk AM, Hill J, Alegana VA, Kirui V, Gething PW, ter Kuile FO, et al.: Coverage of malaria protection in pregnant women in sub-Saharan Africa: a synthesis and analysis of national survey data. Lancet Infect Dis 2011, 11:190-207.
• [45]Pande RP, Yazbeck AS. What’s in a country average? Wealth, gender, and regional inequalities in immunization in India. Soc Sci Med 1982. 2003;57:2075–88.
• [46]Singh PK, Rai RK, Kumar C: Equity in maternal, newborn, and child health care coverage in India. Glob Health Action 2013, 6:22217.
• [47]Wirth ME, Balk D, Delamonica E, Storeygard A, Sacks E, Minujin A: Setting the stage for equity-sensitive monitoring of the maternal and child health Millennium Development Goals. Bull World Health Organ 2006, 84:519-27.
• [48]Lozano R, Soliz P, Gakidou E, Abbott-Klafter J, Feehan DM, Vidal C, et al.: Benchmarking of performance of Mexican states with effective coverage. Lancet 2006, 368:1729-41.
• [49]Noor AM, Mutheu JJ, Tatem AJ, Hay SI, Snow RW: Insecticide-treated net coverage in Africa: mapping progress in 2000–07. Lancet 2009, 373:58-67.
• [50]Liu Y, Rao K, Wu J, Gakidou E: China’s health system performance. Lancet 2008, 372:1914-23.
• [51]Kumar C, Singh PK, Rai RK: Coverage gap in maternal and child health services in India: Assessing trends and regional deprivation during 1992–2006. J Public Health (Oxf) 2013, 35:598-606.
• [52]Boutayeb A, Helmert U: Social inequalities, regional disparities and health inequity in North African countries. Int J Equity Health 2011, 10:23.
• [53]Edward A, Kumar B, Kakar F, Salehi AS, Burnham G, Peters DH: Configuring balanced scorecards for measuring health system performance: Evidence from 5 years’ evaluation in Afghanistan. PLoS Med 2011, 8:e1001066.
• [54]Subramanian SV, Nandy S, Irving M, Gordon D, Lambert H, Davey SG: The mortality divide in India: the differential contributions of gender, caste, and standard of living across the life course. Am J Public Health 2006, 96:818-25.
• [55]De Sherbinin A: The biophysical and geographical correlates of child malnutrition in Africa. Popul Space Place 2011, 17:27-46.
• [56]Sousa A, Hill K, Poz MRD: Sub-national assessment of inequality trends in neonatal and child mortality in Brazil. Int J Equity Health 2010, 9:21.
• [57]Sreeramareddy CT, Harsha Kumar HN, Sathian B: Time trends and inequalities of under-five mortality in Nepal: a secondary data analysis of four demographic and health surveys between 1996 and 2011. PLoS One 2013, 8:e79818.
• [58]Adebayo SB, Fahrmeir L, Klasen S: Analyzing infant mortality with geoadditive categorical regression models: a case study for Nigeria. Econ Hum Biol 2004, 2:229-44.
• [59]Kraft AD, Nguyen K-H, Jimenez-Soto E, Hodge A: Stagnant neonatal mortality and persistent health inequality in middle-income countries: a case study of the Philippines. PLoS One 2013, 8:e53696.
• [60]Pathak P, Singh A: Geographical variation in poverty and child malnutrition in India. In Popul Poverty Health Anal Approaches. Edited by Singh K, Yadava R, Pandey A. Hindustan Publishing Corporation, New Delhi; 2009:183-206.
• [61]Singh A, Pathak PK, Chauhan RK, Pan W: Infant and child mortality in India in the last two decades: a geospatial analysis. PLoS One 2011, 6:e26856.
• [62]Ahmed S, Hill K: Maternal mortality estimation at the subnational level: a model-based method with an application to Bangladesh. Bull World Health Organ 2011, 89:12-21.
• [63]Rai RK, Kumar C, Singh PK: District level coverage gap in maternal, newborn and child health care services in India. J Epidemiol Glob Health 2012, 2:221-4.
• [64]Pullan RL, Freeman MC, Gething PW, Brooker SJ: Geographical inequalities in use of improved drinking water supply and sanitation across sub-Saharan Africa: mapping and spatial analysis of cross-sectional survey data. PLoS Med 2014, 11:e1001626.
• [65]Kumar C, Singh PK, Rai RK: Under-five mortality in high focus states in India: a district level geospatial analysis. PLoS One 2012, 7:e37515.
• [66]Storeygard A, Balk D, Levy M, Deane G: The global distribution of infant mortality: a subnational spatial view. Popul Space Place 2008, 14:209-29.
• [67]Bangha MW, Simelane S: Spatial differentials in childhood mortality in South Africa: evidence from the 2001 census. Afr Popul Stud 2007, 2001:3-21.
• [68]Asiimwe JB, Jehopio P, Atuhaire LK, Mbonye AK: Examining small area estimation techniques for public health intervention: lessons from application to under-5 mortality data in Uganda. J Public Health Policy 2011, 32:1-14. Discussion 15
• [69]Kandala N-B, Ghilagaber G: A geo-additive Bayesian discrete-time survival model and its application to spatial analysis of childhood mortality in Malawi. Qual Quant 2006, 40:935-57.
• [70]Bauze AE, Tran LN, Nguyen K-H, Firth S, Jimenez-Soto E, Dwyer-Lindgren L, et al.: Equity and geography: the case of child mortality in Papua New Guinea. PLoS One 2012, 7:e37861.
• [71]Ram U, Jha P, Ram F, Kumar K, Awasthi S, Shet A, et al.: Neonatal, 1–59 month, and under-5 mortality in 597 Indian districts, 2001 to 2012: estimates from national demographic and mortality surveys. Lancet Glob Health 2013, 1:e219-26.
• [72]Sartorius BK, Sartorius K, Chirwa TF, Fonn S: Infant mortality in South Africa – distribution, associations and policy implications, 2007: an ecological spatial analysis. Int J Health Geogr 2011, 10:61.
• [73]Gemperli A, Vounatsou P, Kleinschmidt I, Bagayoko M, Lengeler C, Smith T: Spatial patterns of infant mortality in Mali: the effect of malaria endemicity. Am J Epidemiol 2004, 159:64-72.
• [74]Kazembe LN, Appleton CC, Kleinschmidt I: Spatial analysis of the relationship between early childhood mortality and malaria endemicity in Malawi. Geospat Health 2007, 2:41-50.
• [75]Kazembe LN, Mpeketula PMG: Quantifying spatial disparities in neonatal mortality using a structured additive regression model. PLoS One 2010, 5:e11180.
• [76]Chin B, Montana L, Basagaña X: Spatial modeling of geographic inequalities in infant and child mortality across Nepal. Health Place 2011, 17:929-36.
• [77]Mulholland E, Smith L, Carneiro I, Becher H, Lehmann D: Equity and child-survival strategies. Bull World Health Organ 2008, 86:399-407.
• [78]Mexican Ministry of Health: Effective Coverage of the Health System in Mexico 2000–2003. Mexican Ministry of Health, Federal District, Mexico; 2006.
• [79]Gakidou E, Lozano R, González-Pier E, Abbott-Klafter J, Barofsky JT, Bryson-Cahn C, et al.: Assessing the effect of the 2001–06 Mexican health reform: an interim report card. Lancet 2006, 368:1920-35.
• [80]Murray CJ, Frenk J: A framework for assessing the performance of health systems. Bull World Health Organ 2000, 78:717-31.
• [81]Ministry of Health: National Health Strategic Plan 2006–2010. Ministry of Health, Republic of Zambia, Lusaka; 2005.
• [82]Ministry of Health: National Health Strategic Plan 2011–2015. Ministry of Health, Republic of Zambia, Lusaka; 2011.
• [83]Programme NMC: A road map for impact on malaria in Zambia: a 6-year strategic plan 2006–2011. Ministry of Health, Republic of Zambia, Lusaka; 2006.
• [84]Programme NMC: Strategic plan for 2011–2015. Ministry of Health, Republic of Zambia, Lusaka; 2011.
• [85]The Partnership for Maternal, Newborn and Child Health. A global review of the key interventions related to reproductive, maternal, newborn and child health. Geneva: PMNCH; 2011.
• [86]World Health Organization. Physical status: the use and interpretation of anthropometry. Report of a WHO Expert Committee. Technical Report Series No. 854. Geneva: World Health Organization; 1995.
• [87]Burton A, Monasch R, Lautenbach B, Gacic-Dobo M, Neill M, Karimov R, et al.: WHO and UNICEF estimates of national infant immunization coverage: methods and processes. Bull World Health Organ 2009, 87:535-41.
• [88]Gakidou E, Cowling K, Lozano R, Murray CJL: Increased educational attainment and its effect on child mortality in 175 countries between 1970 and 2009: a systematic analysis. Lancet 2010, 376:959-74.
• [89]Chowa G, Ansong D, Masa R: Assets and child well-being in developing countries: a research review. Child Youth Serv Rev 2010, 32:1508-19.
• [90]Houweling TAJ, Kunst AE: Socio-economic inequalities in childhood mortality in low- and middle-income countries: a review of the international evidence. Br Med Bull 2010, 93:7-26.
• [91]Shengelia B, Tandon A, Adams OB, Murray CJL: Access, utilization, quality, and effective coverage: an integrated conceptual framework and measurement strategy. Soc Sci Med 2005, 61:97-109.
• [92]Sharp B, van Wyk P, Sikasote JB, Banda P, Kleinschmidt I: Malaria control by residual insecticide spraying in Chingola and Chililabombwe, Copperbelt Province, Zambia. Trop Med Int Health 2002, 7:732-6.
• [93]Chanda E, Masaninga F, Coleman M, Sikaala C, Katebe C, MacDonald M, et al.: Integrated vector management: the Zambian experience. Malar J 2008, 7:164.
• [94]Chanda E, Kamuliwo M, Steketee RW, Macdonald MB, Babaniyi O, Mukonka VM: An overview of the Malaria Control Programme in Zambia. ISRN Prev Med 2012, 2013:495037.
• [95]Foreman KJ, Lozano R, Lopez AD, Murray CJ: Modeling causes of death: an integrated approach using CODEm. Popul Health Metr 2012, 10:1.
• [96]Murray CJ, Rosenfeld LC, Lim SS, Andrews KG, Foreman KJ, Haring D, et al.: Global malaria mortality between 1980 and 2010: a systematic analysis. Lancet 2012, 379:413-31.
• [97]Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al.: Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010, 375:1609-23.
• [98]Rajaratnam JK, Marcus JR, Flaxman AD, Wang H, Levin-Rector A, Dwyer L, et al.: Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970–2010: a systematic analysis of progress towards Millennium Development Goal 4. Lancet 2010, 375:1988-2008.
• [99]World Health Organization (WHO): Annual report of the WHO country office Zambia, 2011. WHO, Lusaka; 2011.
• [100]Wang H, Schumacher AE, Levitz CE, Mokdad AH, Murray CJ: Left behind: widening disparities for males and females in US county life expectancy, 1985–2010. Popul Health Metr 2013, 11:8.
• [101]Danaei G, Rimm EB, Oza S, Kulkarni SC, Murray CJL, Ezzati M: The promise of prevention: the effects of four preventable risk factors on national life expectancy and life expectancy disparities by race and county in the United States. PLoS Med 2010, 7:e1000248.
• [102]Dwyer-Lindgren L, Mokdad AH, Srebotnjak T, Flaxman AD, Hansen GM, Murray CJ: Cigarette smoking prevalence in US counties: 1996–2012. Popul Health Metr 2014, 12:5.
• [103]Brugha R, Simbaya J, Walsh A, Dicker P, Ndubani P: How HIV/AIDS scale-up has impacted on non- HIV priority services in Zambia. BMC Public Health 2010, 10:540.
• [104]Institute for Health Metrics and Evaluation: Health service provision in Zambia: assessing facility capacity, costs of care, and patient perspectives. IHME, Seattle, WA; 2014.
• [105]Sepúlveda J, Bustreo F, Tapia R, Rivera J, Lozano R, Oláiz G, et al.: Improvement of child survival in Mexico: the diagonal approach. Lancet 2006, 368:2017-27.
• [106]Lawn JE, Rohde J, Rifkin S, Were M, Paul VK, Chopra M: Alma-Ata 30 years on: revolutionary, relevant, and time to revitalise. Lancet 2008, 372:917-27.
• [107]Waage J, Banerji R, Campbell O, Chirwa E, Collender G, Dieltiens V, et al.: The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015. Lancet 2010, 376:991-1023.
• [108]Health and the post-2015 development agenda. Lancet. 2013;381:699.
• [109]UNAIDS, UNICEF, UNFPA, WHO. Health in the Post-2015 UN Development Agenda. Thematic Think Piece. UN System Task Team on the Post-2015 Development Agenda. Geneva: UNAIDS; 2012. http://www.un.org/millenniumgoals/pdf/Think%20Pieces/8_health.pdf.
• [110]Stuckler D, Basu S, McKee M: Drivers of inequality in millennium development goal progress: a statistical analysis. PLoS Med 2010, 7:e1000241.
• [111]Gwatkin DR: How much would poor people gain from faster progress towards the millennium development goals for health? Lancet 2005, 365:813-7.
• [112]Easterly W: How the millennium development goals are unfair to Africa. World Dev 2009, 37:26-35.
• [113]Boerma JT, Stansfield SK: Health statistics now: are we making the right investments? Lancet 2007, 369:779-86.
• [114]Murray CJ: Towards good practice for health statistics: lessons from the Millennium Development Goal health indicators. Lancet 2007, 369:862-73.