Introduction

Tremendous progress has been made in reducing mortality among children under the age of five (under-five mortality or U5M), but over 5 million children still die every year, and most of these deaths are from preventable causes .¹ Continued progress in reducing U5M remains a central global health priority. Improving the lives of children around the world is a critical human rights and equity issue and is fundamental to both economic development and quality of life. With this recognition in mind, the international community has kept U5M at the top of its agenda. Ambitious goals, such as the United Nations Millennium Development Goals in 2000 and subsequent Sustainable Development Goals in 2015, have underscored the importance of U5M and the continued need to maintain and expand efforts to reduce it. (For further detail, see the accompanying Topic Page).

Some countries have shown exceptional progress at reducing U5M relative to the global average. While the U5M rate (deaths per 1,000 live births) declined an average of 47 percent in sub-Saharan Africa between 2000 and 2017, a small handful of countries have far exceeded that pace, reducing their child mortality rates by more than 60 percent during the same period. Further still, some countries have done so against odds, reducing child mortality faster than their rate of economic development would suggest is likely. The ongoing burden of U5M underscores the need to learn from examples of countries that have made the most progress.

We present the results of a cross-cutting analysis of six “Exemplar” countries that have made particularly impressive strides to reduce U5M relative to their economic growth: Rwanda, Nepal, Bangladesh, Senegal, Peru, and Ethiopia. The scope of the research was limited to deaths that could be prevented by improvements in health care delivery and quality. Based on implementation research methodologies, the work focused on the decision processes, implementation strategies, and contextual factors that influenced the success of evidence-based interventions between 2000 and 2015.

The research also explored interventions outside the traditional health care system that are known to reduce the risk of major causes of U5M. These include such measures as improved sanitation, broadened access to education, advances in female empowerment, and reductions in stunting. However, an in-depth analysis of how these were implemented and affected U5M was beyond the scope of the project.

The desk review and primary research were informed by the “Exploration, Preparation, Implementation, and Sustainment” (EPIS) implementation research framework first laid out in a 2010 paper by Gregory Aarons, Michael Hurlburt, and Sarah McCue Horwitz.²  The Exemplars research team modified this framework to include a critical fifth step, Adaptation. This augmented framework, abbreviated as EPIAS, describes the key phases of health interventions. Using this EPIAS lens helped frame the actions of Exemplar countries and identify key lessons about decision-making processes and implementation strategies from each of the steps.

The five phases are detailed further below:

• Exploration – Understanding the U5M challenge at hand, drawing upon national research and international evidence.
• Preparation – Laying the groundwork for implementation, including funding, training, and other systems and elements crucial to delivering evidence-based interventions to populations in need. 
• Implementation – Rollout and delivery of the intervention.
• Adaptation – Adjusting evidence-based interventions or implementation strategies as indicated through initial monitoring or emerging evidence.
• Sustainment – Maintaining the implementation of the evidence-based intervention and its benefits over time. This framework forms the lens through which we interpreted implementation strategies used in the Exemplar countries.

Process Followed by Exemplar Countries

Exploration

Policy makers and program leaders in Exemplar countries deliberately sought to understand which available evidence-based interventions may be appropriate and feasible to implement in the country, and what resources would be needed. Leaders used the most current data available and discerned which areas may require additional evidence. Early in the policy-making and planning processes, Exemplar countries also identified equity considerations and stakeholders who were most relevant for guiding implementation of interventions.

Preparation

Leaders in Exemplar countries convened relevant stakeholders to identify financial and technical resources and potential implementation strategies that would be most suitable for national or subnational levels. They also identified contextual factors that may facilitate or hinder implementation and acceptability of evidence-based interventions, such as geographical or cultural considerations. 

Guided by this information, leaders and stakeholders selected evidence-based interventions and implementation strategies that best fit the national and subnational context. They began developing guidelines, tools, and evaluation protocols.

Work during this step of the process helped identify where adaptations or health systems strengthening may be needed to ensure feasibility. Examples of these considerations include new cold-chain infrastructure for vaccinations and supply-chain improvements to expand the delivery of care from health facilities to community health workers. In addition, Exemplar countries made early decisions about where and when to carry out plans and whether to aim for rapid national rollout or a more targeted approach based on need.

Small-scale testing was conducted in some areas to test feasibility and effectiveness in local settings. Leaders of the implementation effort also used this time early in the planning process to connect with partners and donors to secure long-term funding and support.

Implementation

Once plans were in place to reach targeted scale-up, national officials in Exemplar countries coordinated the rollout of selected implementation strategies with an emphasis on ensuring quality assurance, training, and accountability mechanisms necessary for sustaining quality and momentum. Ongoing monitoring of implementation outcomes was also an important component, as was a focus on equity, to ensure that all members of the population were reached.

As implementation got underway, officials identified early gaps in coverage and quality that might hinder nationwide implementation. Implementation plans often included community outreach, engagement, and education activities to support knowledge and awareness of new interventions and strengthen acceptability and uptake.

Adaptation

Officials and partners in Exemplar countries frequently relied on monitoring and evaluation to determine whether significant gaps existed in implementation outcomes and where there were equity gaps. These data were used to assess where modifications might be needed – both for specific evidence-based interventions and the implementation strategies themselves – to support continuous improvement.

Meanwhile, any emergent global insights potentially relevant to implementation were evaluated to assess whether and how they might be incorporated.

Sustainment

Exemplar countries often engaged with a broad range of government stakeholders to ensure long-term sustainability. These multisectoral relationships usually included not only ministries of health, but also other ministries and legislative and judicial functions. Governmental structures integrated new interventions into national systems.

Exemplar countries included provisions for national government oversight, political accountability, and sustained funding. To ensure sustainability, Exemplars introduced early lessons from the initial delivery of interventions into training programs, and integrated them where possible in pre-service training. In addition, Exemplar countries used ongoing measurement of outcomes, quality, and equity to inform adaptations and innovations in support of scale-up goals.

Evidence-Based Interventions and the Burden of Disease 

To understand the achievement of Exemplar countries in reducing U5M, it is first necessary to identify the leading causes of U5M in these countries and the interventions used to address them. The figure below shows the most common interventions used by Exemplars to address leading causes of U5M.

The leading cause of U5M in Exemplar countries is neonatal disorders, which includes preterm birth complications, birth asphyxia, and other conditions. To reduce these, Exemplar countries used a range of interventions related to improving care of the mother and child before, during, and after delivery. The next leading causes of death were lower respiratory infections and diarrhea. To fight these, Exemplar countries delivered vaccines and used a strategy known as Integrated Management of Childhood Illness (IMCI). Other leading causes of death included malaria, meningitis, malnutrition, measles, and HIV – countries used vaccines, treatments, and other interventions to address these. 

Research to understand the experience of introducing and scaling up these interventions has yielded lessons for other countries seeking to reduce U5M in their own countries. These recommendations are summarized in the next section.