Lessons for the Sustainable Development Goals from Ethiopia's success: the case of under-5 mortality
Authors: Yohannes Adama Melaku, Zumin Shi
Journal: The Lancet Global Health (2017)

Low-income countries face many health and development challenges. In response to these challenges, world leaders have taken counter action and formulated the Millennium Development Goals (MDGs), one of which (MDG4) was to reduce the mortality of children younger than 5 years by two-thirds by 2015. In Ethiopia, under-5 mortality was 166 deaths per 1000 livebirths in 2000,1Central Statistical Agency of EthiopiaORC MacroEthiopia Demographic and Health Survey 2000. Central Statistical Agency of Ethiopia and ORC Macro, Addis Ababa and Calverton, MD2001Google Scholar one of the highest in the world. However, by 2016, after 15 years of successful effort, under-5 mortality had decreased to 67 deaths per 1000 livebirths.2Central Statistical Agency and ORC MacroEthiopia Demographic and Health Survey 2016. Central Statistical Agency of Ethiopia and ORC Macro, Addis Ababa and Calverton, MD2017Google Scholar The achievement of MDG4 in Ethiopia is proof that tailored health and health-related interventions and strategies can be successfully implemented in poorly resourced settings.3Balabanova D Mills A Conteh L et al.Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening.Lancet. 2013; 381: 2118-2133Summary Full Text Full Text PDF PubMed Scopus (181) Google Scholar Yet one of the challenges in countries like Ethiopia is understanding how countries progress in achieving the MDGs. It is imperative to systematically document the lessons from countries that have already successfully achieved the MDGs. This will enable other countries to emulate the experiences of these countries and replicate them to solve the same challenge or other health problems in different or similar settings. Using mixed methods to pinpoint the success of Ethiopia in reducing under-5 mortality, Jenny Ruducha and colleagues4Ruducha J Mann C Singh NS et al.How Ethiopia achieved Millennium Development Goal 4 through multisectoral interventions: a Countdown to 2015 case study.Lancet Glob Health. 2017; 5: e1142-e1151Summary Full Text Full Text PDF PubMed Scopus (69) Google Scholar have generated a body of evidence that provides comprehensive information and allows replication of the Ethiopian experience. The case study assessed macro-level factors that have had a potential impact on under-5 mortality, such as national policies, programmes, health financing, and health interventions. Additionally, the authors present the trend and coverage of successful interventions by calendar year and residency, extending their analysis to health equity. The relative contributions of selected interventions designed to reduce under-5 mortality were also estimated. The use of multiple data sources and triangulation of methods are strengths of the study.4Ruducha J Mann C Singh NS et al.How Ethiopia achieved Millennium Development Goal 4 through multisectoral interventions: a Countdown to 2015 case study.Lancet Glob Health. 2017; 5: e1142-e1151Summary Full Text Full Text PDF PubMed Scopus (69) Google Scholar In line with another study,5Deribew A Tessema GA Deribe K et al.Trends, causes, and risk factors of mortality among children under 5 in Ethiopia, 1990–2013: findings from the Global Burden of Disease Study 2013.Popul Health Metr. 2016; 14: 42Crossref PubMed Scopus (53) Google Scholar the authors declare the achievement of MDG4 in Ethiopia, reducing under-5 mortality by 69% between 1990 and 2013. The analysis indicates that half of the averted mortality was due to improvements in child nutrition. Compared with other east African countries, Ethiopia also had the fastest rate of reduction in under-5 mortality between 1990 and 2013.4Ruducha J Mann C Singh NS et al.How Ethiopia achieved Millennium Development Goal 4 through multisectoral interventions: a Countdown to 2015 case study.Lancet Glob Health. 2017; 5: e1142-e1151Summary Full Text Full Text PDF PubMed Scopus (69) Google Scholar It is also encouraging to note that, except for early and exclusive breastfeeding, all other health and health-related indicators included in the analysis showed improvements. Despite this progress, however, coverage disparity and health inequity by geographic areas (across regions, and in rural vs urban areas) remain daunting challenges to Ethiopia's health-care system. It is apparent that this continues to be an important bottleneck for the country's health-care system despite major public health triumphs during the MDG era.6Assefa Y Damme WV Williams OD Hill PS Successes and challenges of the millennium development goals in Ethiopia: lessons for the sustainable development goals.BMJ Glob Health. 2017; 2: e000318Crossref Scopus (71) Google Scholar In future studies, analyses should comprehensively include all policy determinants of under-5 mortality (ie, all major health interventions, including the expansion of HIV care and prevention of maternal-to-child transmission services).7Kerber KJ Lawn JE Johnson LF et al.South African child deaths 1990–2011: have HIV services reversed the trend enough to meet Millennium Development Goal 4?.AIDS. 2013; 27: 2637-2648Crossref PubMed Scopus (31) Google Scholar Maternal factors such as education, dietary intake, and nutritional status also determine child health outcomes. The overall socioeconomic trajectory should be considered in similar studies in the future. Incorporating independent, reliable, and unbiased data sources (including subnational studies) in future analyses will provide additional insights. Ethiopia is facing an unprecedented health phenomenon known as the double/triple burden of diseases, which refers to the coexistence of a high burden of infectious diseases, nutritional disorders, and non-communicable diseases.8Misganaw A Haregu TN Deribe K et al.National mortality burden due to communicable, non-communicable, and other diseases in Ethiopia, 1990–2015: findings from the Global Burden of Disease Study 2015.Popul Health Metr. 2017; 15: 29Crossref PubMed Scopus (94) Google Scholar Health inequities across geographic areas are exacerbating this phenomenon. A reorientation of the health-care system is therefore needed to address this challenge and to ensure health justice in the country. In this respect, Ethiopia has already started a roadmap by endorsing the UN's Sustainable Development Goals (SDGs), 2015–30, a global development initiative with 17 goals, one of which (SDG3) focuses on health (ensure healthy lives and promote wellbeing for all at all ages). It is commendable that the country recognises and uses lessons from the MDGs, sustains successes, and addresses the challenges in future health interventions and strategies to achieve the targets. Ethiopia might also need to redevelop and reformulate targeted strategies, interventions, and programmes by critically analysing the evidence on the current disease epidemiology and demographic transition.8Misganaw A Haregu TN Deribe K et al.National mortality burden due to communicable, non-communicable, and other diseases in Ethiopia, 1990–2015: findings from the Global Burden of Disease Study 2015.Popul Health Metr. 2017; 15: 29Crossref PubMed Scopus (94) Google Scholar Last but not least, informing health investments by actively collating, analysing, and disseminating data should be an integral part of the interventions. In summary, the data presented by Jenny Ruducha and colleagues4Ruducha J Mann C Singh NS et al.How Ethiopia achieved Millennium Development Goal 4 through multisectoral interventions: a Countdown to 2015 case study.Lancet Glob Health. 2017; 5: e1142-e1151Summary Full Text Full Text PDF PubMed Scopus (69) Google Scholar explicitly demonstrate the importance of political commitment, multisectoral policies and strategies, and resource mobilisation in reducing under-5 mortality in low-income countries. An interplay between direct and indirect interventions from different sectors has had a positive effect, but further efforts on other health challenges and a strong partnership between sectors will be necessary to further improve progress. The experience in Ethiopia in reducing under-5 mortality provides further evidence and salient lessons as to how low-income countries can solve existing and future health challenges using innovative and inexpensive interventions in the SDG era. We declare no competing interests. How Ethiopia achieved Millennium Development Goal 4 through multisectoral interventions: a Countdown to 2015 case studyThe reduction of under-5 mortality in Ethiopia was the result of combined activities in health, nutrition, and non-health sectors. However, Ethiopia still has high neonatal and maternal morbidity and mortality from preventable causes and an unfinished agenda in reducing inequalities, improving coverage of effective interventions, and strengthening multisectoral partnerships for further progress. Full-Text PDF Open Access