Countdown to 2030: Data Sources and Technical Review Process – 2016-2017
Most coverage, equity and nutrition data come from standardized population-based surveys (Demographic and Health Surveys, Multiple Indicator Cluster Surveys, and other nationally representative surveys that meet data quality standards). Mortality data are provided by United Nation’s sources and academic collaborations. The Countdown relies upon WHO global databases on policies, health workforce and financing indicators for many of the drivers related analyses. Data on availability of emergency obstetric care comes from UNFPA and the Averting Maternal Death and Disability program, and the legal status of abortion data is from the UN Population Division database for 2015.
Detailed information on the data sources for each of the indicators tracked by Countdown is available in the Countdown Report annexes.
Technical Review Process
Countdown to 2030 builds on the 12 years of monitoring experience of Countdown to 2015. It aims to provide the best and most recent scientific evidence on country-level progress towards improving women’s, children’s and adolescents’ health1, and to improve the use of national data to accelerate attention, accountability and action for scaling up coverage of priority reproductive, maternal, newborn, child, adolescent health and nutrition (RMNCAH&N) interventions.
Countdown adds value to global and country accountability efforts by forging a clear, evidence-based consensus on priority interventions for RMNCAH &N and on key coverage determinants. This consensus is achieved through a rigorous annual technical review process which enables the Countdown partnership to: 1) re-assess its indicator list in response to changes in the evidence base on effective interventions and changes in country priorities, 2) examine the range of equity analyses including stratifiers, 3) to ensure its monitoring efforts are harmonized with other major global, regional and country accountability initiatives, and 4) review the priority country list based on country progress and global and country targets and goals.
Countdown has completed the technical review process for the 2016-2017 reporting year which resulted in updated decisions about the Countdown indicator list, equity analyses, and priority countries. Countdown will continue to produce country profiles populated with an agreed upon core set of indicators, equity specific profiles, and regular reports that summarize data across the Countdown countries.
Countdown priority countries
- Background: country selection during Countdown to 2015 took place in three phases:
- Phase 1. In 2004, Countdown defined a list that included all countries with at least 50,000 child deaths and all countries with an under-five mortality rate of at least 90 deaths per 100,000 live births. The resulting list of 60 priority countries, which were profiled in the2005 Countdown Report, represented almost 500 million children under age five — more than 75% of all such children then living — and represented 94% of all child deaths.
- Phase 2. For the2008 Countdown Report, the list was expanded to include those countries with the highest maternal mortality ratios (all countries with an MMR of more than 550 deaths per 100,000 live births) or highest numbers of maternal deaths (all countries with at least 750 maternal deaths, and an MMR of more than 200). Because countries with high child mortality overlapped significantly with those that had high maternal mortality, this exercise led to the inclusion of only eight additional Countdown priority countries. This list of 68 countries was also used in the 2010 Countdown Decade Report.
- In 2011, with Countdown’s agreement to take responsibility for major parts of the follow-up agenda of theCommission for Information and Accountability for Women’s and Children’s Health, Countdown’s list of priority countries was again expanded to 75 countries. The 75 countries included the 68 high-burden countries described above as well any of the 49 low-income countries discussed in the first Global Strategy for Women’s and Children’s Health not previously included. Between 2012 and 2015, Countdown produced annual reports and analyses of country-specific information on key indicators for each of these 75 countries.
- Countdown to 2030, country selection for 2017:
The process for selecting the country list for 2017 was in keeping with the evidence-based process used during Countdown to 2015. It involved reviewing the criteria for country selection used in Countdown to 2015, assessing country levels and trends of maternal, newborn and child mortality (as well as absolute numbers of deaths), and taking into consideration country lists used in other major global initiatives (i.e., SDG, GFF, FP2020, GS 2.0, GNR, etc.).
- Prioritized a set of 81 countries based on maternal, newborn, and child mortality burden. The full 2-page country profiles will be prepared for each of these countries.
- Identified a sub-set of core indicators for all of the world’s countries, including high income countries (e.g., mortality, stillbirths, fertility, vaccine indicators, etc.).
- Started work on preparing special profiles for conflict-affected countries/fragile states, some of which are not included as part of the list of 81 countries.
Countdown to 2030 used the following criteria to select the 81 priority countries:
- Exclusion of high mortality countries with less than 500,000 population in 2015
- Countries with U5MR > 25 per 1,000 live births and/or MMR > 70 per 100,000 live births *
- Compatibility with other agency lists: low or middle-income countries; IDA countries; GFF priority countries; other lists
The application of these criteria resulted in three country groupings (see figure):
- Group 1 countries: 53 (51 were CD2015 countries) countries with a U5MR and/or MMR above the SDG target and included in countries accounting for 95% of all U5 or maternal deaths
- Group 2 countries: 28 countries (17 were in CD2015) with a U5MR and/or MMR above the SDG target but NOT included in countries accounting for 95% of all U5 or maternal deaths
- Group 3 countries: 9 countries (of which 6 were in CD2015) with a U5MR and MMR below the target but included in countries accounting for 95% of all U5 or maternal deaths. These countries are all upper-middle or high income countries.
- The final list of Countdown priority countries includes the countries in groups 1 and 2, resulting in a total of 81 countries. As noted above, Countdown is in the process of developing a template for country profiles specific to conflict affected countries.
- Countries previously included in Countdown to 2015 and that ‘graduated’ include: Brazil, China, Egypt, Peru, and Vietnam. Sao Tome e Principe was excluded because of its small population size. Newcomers to Countdown include: Algeria, Bhutan, Dominican Republic, Guyana, Honduras, Jamaica, Namibia, Nicaragua, Panama, Paraguay, Suriname, Timor-Leste and Venezuala.
- *We are aware that a MMR of 70 per 100,000 is a global target whereas a U5MR of 25 per 1,000 is a national target, but we opted to use these figures because they are recognized as SDG goals
Figure. Country lists, groups 1, 2 and 3 as part of the Countdown country selection process, 2017
Map of the Countdown countries
Countdown interventions and indicators
Countdown’s selection of priority interventions and indicators is guided by the summary impact model (see below). The main focus of Countdown is coverage – the proportion of individuals needing a service or intervention who actually receive it. All interventions tracked through Countdown are scientifically proven to improve health and survival among mothers, newborn, children or adolescents. Coverage of service contact indicators, such as antenatal and postnatal care, childbirth, and family planning services also need to be tracked, as they provide the basic platform for delivery of multiple effective interventions. Ideally, Countdown will be able to increasingly track the actual content of care received during these service contacts as data becomes more available and as measurement improves. Countdown is focusing attention through the coverage technical working group on improving measures of effective coverage which take into consideration the quality and content of care. Selected indicators for Countdown’s global monitoring activities (i.e., the profiles and global reports) include those that are valid, reliable, comparable across countries and time, nationally representative, and useful for policy makers and program managers.
The technical review process for 2017 provided an opportunity for Countdown to review and update the indicator list so that it reflects the latest evidence on effective interventions for RMNCAH&N. Countdown has agreed to continue to report on the full continuum of care, and to expand its analyses in the areas of reproductive and adolescent health and nutrition. This process took advantage of the extensive indicator consultations that have taken place in the recent past for developing the SDG framework, the Monitoring Framework for the Global Strategy for Women’s, Children’s, and Adolescent Health, and for other initiatives and efforts such as Every Newborn Action Plan (ENAP), Ending Preventable Maternal Mortality (EPMM), Global Nutrition Report (GNR), the Lancet Commission on Adolescent Health, FP2020, WHO list of 100 core indicators, Primary Health Care Performance Initiative, etc.
The 2017 technical review process proceeded in two phases. Phase 1 concerned the selection of the demographic and coverage indicators, and revision of the list of stratifiers used for the equity analyses. Phase 2 involved the selection of the determinants/drivers of coverage indicators (e.g., the health systems, policies, and financing indicators), which was dependent upon the finalization of the selection of the coverage and demographic indicators since they should be linked/on the same causal pathway.
In each phase, the following general steps were undertaken:
- Mapping of indicators (creating separate files for demographic, coverage, and determinants/drivers indicators that show indicator lists by major global initiatives and how they overlap);
- Creation of a matrix that includes details for each indicator such as numerator, denominator, and data sources;
- Ranking/organizing the indicators into three tiers. In general, Tier 1 indicators are those that are included on the 2-page country profiles. Tier 2 indicators are complementary or additional to Tier 1 indicators and will be reported on the CD website only in the interactive version or ‘dashboard’ version of the country profiles. Tier 3 indicators capture information about proven interventions, but data is not yet readily available for them or they are still under development or aspirational;
- Consultation with technical working group members and additional content area experts (i.e., experts working on WASH, nutrition, malaria, etc.) on the matrix and tiered ranking of the indicators;
- Solicitation of feedback from the broader group of Countdown partners (all those with logos on the back of the 2015 report were invited to provide comments on the indicator lists and to submit proposals for changes to existing indicators or to add indicators)
- Finalization of the list through consensus in the working groups and in the Technical Review Group
The final coverage, drivers and demographic indicator lists are presented by tier in the tables below.
Countdown to 2030 equity analyses
Decisions on the scope of the equity technical working group included:
Stratification of indicators by:
- Wealth quintiles
- Woman’s education
- Woman’s age (current, at child’s birth)
- Urban/rural residence
- Region of the country
- Sex of child (relevant outcomes)
New stratifiers that the group is examining and using for specific analyses:
- Double stratification – wealth quintiles x urban/rural
- Wealth deciles
The group disaggregates the following indicator (using the stratifiers listed above):
- Coverage indicators
- Nutritional status
- Mortality (neonatal, infant, under-5)
- Fertility (total, adolescent)
The equity technical working group is expanding its analyses to include:
- Large set of new SDG indicators related to RMNCH and nutrition
- Contraceptive use and FPC for modern methods and for sexually active women
Data sources and analysis
Households surveys, notably DHS and MICS, are the primary source of data for the coverage indicators. The estimates for the coverage indicators are based on analyses of statistics from UNICEF’s global databases and WHO’s Global Health Observatory by the Johns Hopkins Bloomberg School of Public Health’s Institute for International Programs. The estimates for the disaggregated coverage indicators are based on analyses by the University of Pelotas’ International Centre for Equity in Health.
The Countdown uses mortality and cause of death estimates from United Nations Interagency groups and academic collaborations for its analyses. The Countdown relies upon WHO global databases on policies, health workforce and financing indicators for many of the drivers related analyses. Data on availability of emergency obstetric care comes from UNFPA and the Averting Maternal Death and Disability program, and the legal status of abortion data is from the UN Population Division database for 2015. Analyses on official development assistance were done by the London School of Hygiene and Tropical Medicine based on data from the OECD Creditor Reporting System database.