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 (MNCH) implementation strength and child survival in rural Tanzania from 2011-2015. Measuring this relationship is crucial to improve health outcomes and inform decision-making by identifying which interventions are most effective, where gaps exist, and how to strengthen primary health care systems. We used data from a 2011 service availability and readiness assessment that quantified health facilities' ability to implement MNCH services and a household survey that measured MNCH service utilization to develop domain-specific summary measures of the effective coverage of MNCH. We reduced domain-specific effective coverage scores into fewer, independent scales of implementation strength of services that were delivered by facilities using principal components analysis and 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 and second scales, which represented general facility readiness and the provision of preventive MNCH and sick childcare services, respectively, were associated with child mortality risks that were significantly lower (HR = 0.59, 95% CI = 0.37, 0.92; HR = 0.50, 95% CI = 0.27, 0.94). We detected no significant child mortality response to our third scale, which represented intrapartum care provision. The findings have implications for MNCH policy and health systems measurement. First, the analysis suggests that strong implementation of antenatal, postnatal, early childhood preventive services and sick childcare can accelerate child mortality reduction. Furthermore, the analysis demonstrates a methodological approach for using routine data on service availability and readiness to measure health systems strengthening and its impacts.