The national mortality rate in children younger than 5 years decreased rapidly from 218 child deaths per 1000 live births (95% CI 183–252) in the period 1987–1991 to 88 child deaths per 1000 live births in the period 2007–2011 (95% CI 78–98) with an average annual change of –4.5%. The mortality rate was significantly lower in urban areas, compared to rural areas up until the most recent period (2007–2011) where the confidence intervals for the two estimates overlap indicating that the urban mortality estimate was no longer significantly different from the rural estimate ( Figure 1 ). Large declines in mortality were also noted in the poorest wealth quintile and among mothers with no education (see Figure S2 and Figure S3 in Online Supplementary Document(Online Supplementary Document) ).

Figure 1.  Under–5 mortality rates nationally and in urban and rural areas, Ethiopia, 1987–2011. Data are from analysis of the 2011 national Demographic and Health Survey (DHS) in Ethiopia. Vertical lines show 95% confidence intervals for survival probabilities for the rural and urban estimates. Dates on the x–axis represent the 5–year periods preceding the 2011 Ethiopia DHS. *The 2015 estimate is from the IGME child mortality database (source: UNICEF, [1]).

Significant improvements in the coverage of interventions relevant to child survival in rural areas of Ethiopia between 2000 and 2011 were noted for all indicators except for vitamin A coverage, breastfeeding initiation, exclusive breastfeeding, skilled attendance at birth and postnatal care ( Figure 2 ). Coverage of breastfeeding initiation and exclusive breastfeeding remained high (around 50%) throughout the period of analysis, skilled attendance at birth and postnatal care remained low (<5%) and vitamin A supplementation coverage remained at around 50%. Coverage of improved water source and sanitation, DPT3 and ORS achieved greater gains in the 2000–2005 period while coverage of careseeking for suspected pneumonia and measles vaccination had larger percentage point gains in the 2005 to 2011 period.

Figure 2.  Rural coverage levels for high impact interventions across the continuum of care in Ethiopia as measured in Demographic and Health Surveys (DHS); 2000, 2005 and 2011. Bars represent 95% confidence intervals. DPT3 – three doses of diphtheria, pertussis and tetanus vaccine; ORS – oral rehydration salts; Breastfeeding initiation refers to newborn babies put to the breast within 1 hour of birth; Tetanus Toxoid – percentage of women with a live birth in the last 2 years who received at least 2 doses of tetanus toxoid vaccine during the last pregnancy; PNC – percent of women with live births in the past 2 years who received postnatal care within 2 days after delivery; EBF – exclusive breastfeeding.

With regard to malaria indicators, increases were noted in timely care–seeking for fever and malaria treatment, the largest being for timely care–seeking for fever rising from 16% to 51%. There was little change in coverage of children under–5 sleeping under insecticide–treated nets (ITNs) (41% to 38%) ( Figure 3 ).

Figure 3.  Coverage of malaria interventions in malaria endemic areas of Ethiopia, Malaria Indicator Surveys 2007 and 2011. ITN – insecticide treated nets.

Overall, the prevalence of moderate or severe stunting in children aged 6–35 months declined significantly across both survey periods (2000–2005 and 2005–2011) ( Figure 4 , panel A) with an overall reduction of 13 percentage points (pp). The proportion of children who were moderately or severely underweight also declined significantly among children 6–35 months between 2000 and 2005 (by 11 pp) but did not change significantly between 2005 and 2011. The same trend was seen across all age groups ( Figure 4 , panel B).

Figure 4.  Prevalence of stunting (A) and underweight (B) by age in children in Ethiopia in the Demographic and Health Surveys (DHS); 2000, 2005 and 2011.

Starting at a baseline mortality rate for children younger than 5 years of 146 per 1000 livebirths in 2000 and using available mortality and coverage data up until 2011, LiST predicted under–five mortality to be 119 in 2011, much higher than both the IGME 2011 estimate of 71 (56 to 88) and the 2007–2011 5–year DHS estimate of 88 (78 to 98), and placing it outside the upper confidence range of both estimates.

We calculated the proportion of child lives saved in 2011, by intervention or change in nutritional status, using the LiST estimation of 60 700 deaths averted in 2011 (relative to the situation in 2000) as a denominator. The main factors contributing to the prevention of these deaths in 2011 included nutritional interventions resulting in decreases in wasting rates (18%, 11 400 deaths averted) and stunting rates (13%, 8400 deaths averted), water, sanitation and hygiene (WASH) interventions (13%, 8300 deaths averted), ORS for diarrhea (11%, 7200), and the introduction of the Hib vaccine (10%, 6400 deaths averted) ( Figure 5 ). Decreases in breastfeeding rates between 2005 and 2011 resulted in an additional 2300 deaths.

Figure 5.  Percentage of child lives saved in 2011 in Ethiopia, by intervention. ACTs – Artemisinin–based combination therapies, ITN – insecticide treated nets, ORS – oral rehydration solution, WASH – water, sanitation and hygiene.

Ethiopia has achieved a remarkable decline in under–5 mortality which has occurred in both rural and urban areas and among the poorest and least educated mothers. Our analysis of rural coverage for child survival interventions shows significant change between 2000 and 2011 for several high impact interventions including measles and DPT immunization, ORS coverage, access to an improved water source and care–seeking for suspected pneumonia. For several indicators the biggest coverage change occurred between 2000 and 2005 (tetanus toxoid, DPT3, improved water source and sanitation facilities and ORS) possibly reflecting early impact from the HEP, initiated two years prior to the 2005 DHS, particularly elements such as outreach services, greater access to curative care at health post level, the multi–sectoral approach and a focus on prevention and promotion through model families. Coverage of care–seeking for suspected pneumonia and coverage of ORS treatment for diarrhea was still low in 2011 (both around 25%) although this represents a significant increase from very low coverage levels (around 10%) for both indicators in 2000.

With respect to nutritional status of children, we report a significant decline in both stunting and underweight nationally and our LiST analysis has found that a total of 31% of deaths averted were estimated to be due to decreases in stunting and wasting rates. These shifts in nutritional status of children do not appear to be driven by improvements in breastfeeding practices as exclusive breastfeeding remained high across the period 2000–2011 at around 50% of infants 0–6 months. The changes could plausibly be due to major policy shifts in nutrition which occurred in the country between 2004 and 2008 with the scale up of community management of acute malnutrition at health post level and the development of a national nutrition strategy and program [5,19]. An impact evaluation of the community–based nutrition program in four regions, delivered by HEWs and community volunteers, found substantial changes in infant and young child feeding (increased exclusive breastfeeding) and reductions in stunting prevalence [20]. Furthermore, a recent ecological analysis of patterns in stunting and coverage of nutritional programmes concluded that between 2005 and 2011 the scale up of national nutritional programmes could plausibly have led to reductions in stunting [21].

It is difficult to disentangle the mechanisms whereby socio–economic change and improvements in health coverage interact to generate mortality reduction as these mechanisms can be either direct or indirect and take place concurrently [22]. There are a number of possible explanations for the discrepancy between the IGME–estimated under–five mortality rate and that estimated through our LiST analysis. First, some high impact interventions lack coverage data and so cannot be included in model. Second, it is likely that other contextual changes had influence, which are not captured in LiST. At an economic level, large changes have occurred in the per capita GDP which tripled since 2000 to US$ 355 in 2011; similarly per capita expenditure on health tripled to reach US$ 17.5 in 2011. Furthermore, Ethiopia has received considerable official development assistance (ODA) for maternal, newborn and child health (MNCH) and has successfully guided partner support toward the health sector development program enabling joint financing to ensure implementation of government policies and plans [23]. The annual MNCH ODA has increased from $105 million in 2003 to US$ 215 million in 2010 [24]. Since 2003, Ethiopia has also received US$ 1.4 billion from the Global Fund, 64% of which was spent on HIV/AIDS and between 2004 and 2011 Ethiopia received US$ 1.78 billion from the United States President’s Emergency Plan for AIDS Relief (PEPFAR) [25]. As a result, external resources for health, as a percentage of total health expenditure, increased from 16% in 2000 to 52% in 2011 [26]. This massive funding input could plausibly have had spillover effects on wider health system strengthening beyond the actual programmes it targeted [27,28].

In addition to meeting the MDG 4 target, Ethiopia has also met four other MDG targets including MDG 1 (poverty and hunger), MDG 6 (HIV, malaria and other diseases) and MDG 7 (environmental sustainability). Furthermore at the end of 2015 the country was “on track” to meet MDGs 2 (universal primary education), 3 (gender equality and empowering women) and 5 (maternal health) and was only “off track” on one out of the eight goals (stabilizing debt) [29]. Evidence is emerging that progress made across these multiple sectors which address crucial health determinants has contributed to the fast–track progress in reducing maternal and child mortality in Ethiopia [23,29,30]. This progress does come with some cautionary optimism given the increasing reliance on external resources for health. Other authors have noted this as a challenge facing Sub–Saharan African countries in the post–MDG era. English et al. [31] note that official development assistance (ODA) for health per capita/y in the WHO African Region increased from US$ 2.7 in 2002 to US$ 9.8 in 2010 and while governments’ spending on health has increased, only 6/46 countries in sub–Saharan Africa have met their Abuja target of 15% of their expenditure on health [31].

Several indicators, particularly related to maternal and newborn intervention coverage, showed no improvement in rural areas over the period under analysis. Rural skilled attendance at birth and postnatal care coverage were 4% and 3% respectively in 2011. An analysis of neonatal mortality in Ethiopia found an annual rate of decline of 1.9% between 1995 and 2010, which was even lower (0.9%) for early neonatal mortality (death occurring before 7 completed days of life) the period in which 74% of neonatal deaths occurred [32]. A recently completed 2014 mini–DHS reveals some improvement in these indicators which have reached 9% and 7% respectively, in rural areas in 2014 [33]. Improvement is also seen in another important maternal indicator namely the total fertility rate which has declined from 5.5 in 2011 to 4.5 in 2014 in rural areas. These recent improvements in maternal indicators together with the 2013 launch of community–based newborn care [34] (including sepsis treatment) will hopefully enable the mortality reductions to continue with accelerated progress in reducing newborn deaths.

The endline data for this assessment, the 2011 Ethiopia DHS, occurred at the time of national scale up of the iCCM program and thus provides a picture of coverage and child survival in the absence of an established community–based treatment platform. It is recommended that a comparable analysis be undertaken following the next full DHS to establish the impact of the community delivery platform on child survival and health.