Annual Rates of Decline in Child, Maternal, Tuberculosis, and Noncommunicable Disease Mortality across 109 Low- and Middle-Income Countries from 1990 to 2015

A country’s performance in health is typically defined by how much better or worse it performs with respect to a particular outcome (for example, life expectancy) compared with what would be expected in light of certain contextual attributes (for example, income and education) (Jamison and Sandbu 2001). In Good Health at Low Cost, Halstead, Walsh, and Warren (1985) used a case study approach to assess country performance in levels of mortality, examining why three countries and one Indian state had low levels of mortality despite scant resources. Later analyses also quantified performance with respect to levels of mortality and fertility (Wang and others 1999).

The number of deaths is affected strongly by long-standing country-level determinants. Essentially, a country that starts with a low level of mortality is likely to continue to have lower mortality, whereas a country that begins with a high level of mortality might improve substantially but still have comparatively high mortality. Examining alterations in the number of deaths or annual rate of change in mortality is useful for understanding how a country’s health performance might relate to adjustments in policy. Most published work on country performance is based on estimates of mortality levels, but some studies investigate rates of change (Bhutta and others 2010; Croghan, Beatty, and Ron 2006; Kassebaum and others 2014; Lozano and others 2011; Muennig and Glied 2010; Munshi, Yamey, and Verguet 2016; Verguet and Jamison 2013a, 2013b, 2014; Wang and others 2014). To the extent that rates of change respond to the introduction of health policies (for example, a new immunization program), rates of decline in mortality offer a dependent variable with which to understand the effect on performance of social and system determinants. Nevertheless, the measure—like any one-dimensional metric—still has weaknesses. Notably, large declines from high levels of mortality may still leave an unacceptably large number of deaths. Therefore, rates of change complement rather than replace the important information conveyed by estimates of mortality levels.

The need to measure progress in health was especially apparent when assessing whether countries were on track to achieve the Millennium Development Goals (Bhutta and others 2010; Kassebaum and others 2014; Lozano and others 2011; Wang and others 2014). Measuring progress is also crucial to determining whether countries can achieve the next set of post-2015 Sustainable Development Goals (SDGs) that were adopted by United Nations (UN) member states in 2015. The SDGs include health goals with an associated set of targets; the Lancet Commission on Investing in Health proposed a target of achieving a “grand convergence in global health” by 2035, defined as reducing infectious, maternal, and child deaths to universally low levels, similar to today’s rates in the best-performing middle-income countries, such as Chile and Turkey (Jamison and others 2013). Other targets were proposed by the Global Investment Framework for Women’s and Children’s Health (Stenberg and others 2014), the United Nations Children’s Fund (UNICEF 2013), the Sustainable Development Solutions Network (SDSN 2013), and the High-Level Panel on the post-2015 development agenda (Norheim and others 2015; Peto, Lopez, and Norheim 2014; UN 2013). All of these proposals were debated before adoption of the SDGs by all UN member states.

Studying historical rates of change (rates of decline) in mortality across countries over recent decades can be helpful for testing the feasibility of these different proposals and the SDGs, which include ambitious targets for child, maternal, tuberculosis, human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), and noncommunicable disease (NCD) mortality that would require high rates of decline from 2015 to 2030. Such targets for mortality can be tested for their feasibility by looking at whether high rates of decline in mortality have ever been achieved by any low- or middle-income country (LMIC) and whether similar declines could be achieved in 2016–30.

Assessing a country’s health performance with respect to changes in rates of decline in mortality is, therefore, valuable for studying the effects of policy and for testing the feasibility of proposed post-2015 health goals. This chapter updates a previous study (Verguet and others 2014) that examined changes in the annual rate of decline of key mortality indicators for 109 LMICs by expanding the period to cover 1990–2015. In addition, we examine annual rates of decline in NCD mortality (the probability of dying between ages 50 and 69 years from NCDs in the presence of other causes) over 1993–2013.