Measuring the strength of maternal, newborn and child health care implementation and its association with childhood mortality risk in three rural districts of Tanzania

This observational cohort study explores the association between maternal, newborn and child health care implementation strength and child survival in rural Tanzania from 2011-2015. We used data from a 2011 service availability and readiness assessment that quantified primary health care facilities ability to implement maternal, newborn and child health services and a population-level household survey that measured the utilization of such services to develop domain-specific summary measures of the effective coverage of facility-based maternal, newborn and child health care. We reduced domain specific effective coverage scores into fewer, independent scales of implementation strength using principal components analysis, and integrated them into gradients of the collective implementation strength exerted by groups of facilities on villages they served using Bayesian mixed effects models. We linked these scales to longitudinal data on the survival of children that were born in the catchment areas of the surveyed health facilities during the assessment period and followed up until December 31, 2015. We fit survival time models to estimate the relationship between implementation strength and child mortality. Increases in the implementation strength gauged by our first scale, which represented general facility readiness and the provision of antenatal, postnatal, and early childhood preventive services, were associated with child mortality risks that were, on average, 0.62 times lower. Increases in implementation strength gauged by our second scale, which represented sick childcare service provision, were associated with child mortality risks that were, on average, 0.56 times lower. We detected no significant child mortality response to our third scale, which represented intrapartum care provision. The findings suggest that strong implementation of antenatal, postnatal, early childhood preventive services and sick child care can accelerate child mortality reduction and that routine data on service availability and readiness can be used to measure health systems strengthening and its impacts.