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Volume 16 Supplement 2
Countdown to 2015 country case studies: analysing progress towards maternal and child survival in the Millennium Development Goal era
Research | Open | Published: 12 September 2016
Countdown to 2015 country case studies: what have we learned about processes and progress towards MDGs 4 and 5?
Corrina Moucheraud1,
Helen Owen2,
Neha S. Singh2,
Courtney Kuonin Ng3,
Jennifer Requejo4,
Joy E. Lawn2,
Peter Berman3 &
the Countdown Case Study Collaboration Group
Countdown to 2015 was a multi-institution consortium tracking progress towards Millennium Development Goals (MDGs) 4 and 5. Case studies to explore factors contributing to progress (or lack of progress) in reproductive, maternal, newborn and child health (RMNCH) were undertaken in: Afghanistan, Bangladesh, China, Ethiopia, Kenya, Malawi, Niger, Pakistan, Peru, and Tanzania. This paper aims to identify cross-cutting themes on how and why these countries achieved or did not achieve MDG progress.
Applying a standard evaluation framework, analyses of impact, coverage and equity were undertaken, including a mixed methods analysis of how these were influenced by national context and coverage determinants (including health systems, policies and financing).
The majority (7/10) of case study countries met MDG-4 with over two-thirds reduction in child mortality, but none met MDG-5a for 75 % reduction in maternal mortality, although six countries achieved >75 % of this target. None achieved MDG-5b regarding reproductive health. Rates of reduction in neonatal mortality were half or less that for post-neonatal child mortality. Coverage increased most for interventions administered at lower levels of the health system (e.g., immunisation, insecticide treated nets), and these experienced substantial political and financial support. These interventions were associated with ~30–40 % of child lives saved in 2012 compared to 2000, in Ethiopia, Malawi, Peru and Tanzania. Intrapartum care for mothers and newborns -- which require higher-level health workers, more infrastructure, and increased community engagement -- showed variable increases in coverage, and persistent equity gaps. Countries have explored different approaches to address these problems, including shifting interventions to the community setting and tasks to lower-level health workers.
These Countdown case studies underline the importance of consistent national investment and global attention for achieving improvements in RMNCH. Interventions with major global investments achieved higher levels of coverage, reduced equity gaps and improvements in associated health outcomes. Given many competing priorities for the Sustainable Development Goals era, it is essential to maintain attention to the unfinished RMNCH agenda, particularly health systems improvements for maternal and neonatal outcomes where progress has been slower, and to invest in data collection for monitoring progress and for rigorous analyses of how progress is achieved in different contexts.
The Millennium Development Goals (MDGs) period concluded in 2015, and a plethora of reports were released to assess progress made. MDGs 4 and 5 were at the heart of the health-related MDGs. MDG 4 called for a reduction of childhood (under age 5) mortality by two-thirds, and MDG 5 focused on the improvement of maternal health through a reduction of maternal mortality by three-quarters and a later addition of MDG-5b regarding universal access to reproductive health [1]. Although maternal and child mortality have been reduced by almost 50 % since the 1990s [2], progress is varied across and within countries, and some aspects – such as newborn survival and reproductive health – received less attention until recently and have seen slower progress [3]. In addition to varied progress between different outcomes, there are major differences in progress between countries, even neighbouring countries and understanding these differences is key to informing future progress.
Countdown to 2015 (Countdown) was established in 2005 as a multi-disciplinary, multi-institutional collaboration to track progress towards MDGs 4 and 5 in the 75 countries where more than 95 % of all maternal, newborn and child deaths occur. Countdown uses country-specific data to stimulate and support country progress, to promote accountability of governments and development partners, to identify knowledge gaps, and to propose new actions to reduce newborn and child mortality and improve maternal health [1].
To complement its global monitoring effort, Countdown undertook in-depth country case studies to improve understanding of the causes and processes that underpinned or detracted from achievement of MDGs 4 and 5. A secondary aim of the case studies was to strengthen country-level capacity to conduct research, and to monitor progress in reproductive, maternal, newborn and child health (RMNCH) within countries. Countdown country case studies were led by national investigators with support from the global Countdown team and from Countdown's four technical working groups: coverage, equity, health systems and policies, and financing. This work drew upon Countdown's approach of linking changes in health outcomes to changes in intervention coverage and key coverage determinants, such as equity, policies and systems, and financing. The standard Countdown evaluation framework is displayed in Fig. 1 (supplementary information on the evaluation framework and analyses is available in Additional file 1).
Evaluation framework for Countdown to 2015 country case studies. Source: Afnan-Holmes et al. [11]
The first set of case studies (phase 1), carried out in Niger and Bangladesh, were published in The Lancet in 2012 and 2014 respectively [4, 5] and contributed to the development of a standardised analysis approach that has been applied in subsequent case studies. A second phase of case studies was undertaken in Afghanistan [6], Ethiopia [7], Malawi [8], Pakistan [9], Peru [10], and Tanzania [11]. China and Kenya (phase 3) were added later (Fig. 2) (further details on the case studies are provided in the Additional file 1).
Overview of the case study country selection, geography and focus along the continuum of care accounting to R (reproductive), M (maternal), N (newborn) and C (child) health
The objectives of this paper are to:
Compare quantitative data to evaluate MDG 4 and 5 progress, and changes in coverage, equity and national context, in the case study countries (depending on data availability per indicator): Afghanistan, Bangladesh, China, Ethiopia, Kenya, Malawi, Niger, Pakistan, Peru, and Tanzania.
Use content analysis methods to explore factors that may have enabled or hindered progress towards achieving MDGs 4 and 5 across the six countries with publicly available case study results at the time of publication: Afghanistan, Ethiopia, Malawi, Pakistan, Peru, and Tanzania.
For this cross-cutting analysis, all case study materials – including reports, manuscripts, papers and presentations from each team and from three capacity building workshops (details on these workshops are available at (http://www.countdown2015mnch.org) [12] – were reviewed by study authors to identify factors leading to and detracting from progress on MDGs 4 and 5. We consulted with experts from each of the Countdown technical working groups as well as the case study teams to validate our findings. More details on the methodologies are presented below, and in the Additional file 1. Figure 2 presents an overview of the case study countries, including their geography and case study's focus across the RMNCH continuum. Each country case study should be referred to for full detail about its findings and implications.
The first two case study countries (Bangladesh and Niger) were selected based on data availability and existing strong partnerships between Countdown members and in-country research institutions. In response to substantial interest from other countries for similar analyses, Countdown pursued a portfolio of additional case studies. Nine of the 75 Countdown countries (selected based on data availability and non-duplication with other in-depth analyses) were asked to submit proposals; six country teams were ultimately selected in February 2013 to write full case studies ("phase 2"). Early in 2014, an additional nine countries submitted proposals, from which two additional case study teams were selected. (Further details on this process are available in Additional file 1: Figure B.1-2.)
Objective 1: Compare quantitative data to evaluate MDG 4 and 5 progress, and changes in coverage, equity and national context
Analysis overview and objectives
Quantitative data on the Countdown case study countries were analysed across the evaluation framework (Fig. 1).Footnote 1 The analysis aimed to assess the countries' progress toward MDGs 4 and 5 by systematically evaluating trends since 1990 in impact indicators, coverage of key indicators across the RMNCH continuum of care (CoC), and changes in political, economic and social factors. Additionally, this analysis compared case study country results on the contribution of health intervention coverage to childhood mortality change since the year 2000. Each analysis included those case study countries with available data; Additional file 1: Table B.2-1 displays the representation of countries within the quantitative results presented in this paper.
This cross-cutting analysis examined impacts, intervention coverage and equity, the role of intervention coverage change on mortality declines, and social and economic indicators. Data sources and methods are described in more detail in Additional file 1 section B.2. Data on impact indicators were obtained from the most recently published United Nations estimates at the time of this analysis [13–17]. Information on coverage and equity was obtained for select indicators recommended by the United Nations Commission on Information and Accountability (CoIA) for Women's and Children's Health from the 2015 Countdown report and database [18]. Changes per year for impact and coverage indicators were calculated using the standard formula for annual average rates of change. The Lives Saved Tool (LiST) was used to estimate how changes in the coverage of key interventions may be associated with mortality change at the national level; results from the countries' own LiST analyses [7, 8, 10, 11, 19] are reported here. More detail on the LiST methodology overall can be found in the literature [20]. Data for the social and economic indicators investigated here are those utilised by the Maternal and Child Epidemiology Estimation group (omitting those that overlap with coverage, outcome or impact indicators otherwise investigated by the case study teams) [21].
Objective 2: Undertake content analysis research to explore factors that may have enabled or hindered progress towards achieving MDGs 4 and 5
A content analysis was undertaken of five of the "phase 2" case studies,Footnote 2 to systematically identify the core themes emerging from the Countdown country case studies, based on the evaluation framework (Fig. 1) and the World Health Organisation (WHO) health systems building block model [22]: to explore how progress towards MDGs 4 and 5 was achieved (or not), by examining patterns in and relationships between coverage level and trends and key health systems and contextual factors.
Two authors (HO, CN) independently reviewed all final case study manuscripts and reports and identified factors that hindered or enabled progress across the content areas in the evaluation framework (see Additional file 1) by the categories of reproductive health, maternal health, child health, and newborn health. All relevant information was manually extracted from the manuscripts, and organised by country into an Excel spreadsheet (Additional file 1 section B.3).
The collated information was then synthesised using the WHO health systems building block framework to identify similarities and differences across countries. The case studies only included comparable and pertinent information on five of the six input variables included in the WHO health system building blocks [22]: governance and leadership; health systems financing; health workforce; service delivery; and infrastructure and commodities (i.e., information systems was not included). Non-health sector factors posited by the teams as influencing health system functionality and health outcomes in their respective countries were also examined.
Results were then verified through consultation with the country teams. The principal investigators from each of the country teams were asked via email and a webinar to review the initial content analysis results and to confirm the validity (consistent with their understanding of their country's experience) and comprehensiveness of the findings. Based on these consultations, the results were revised as relevant and finalised.
All Countdown case study countries achieved reductions in fertility and all mortality indicators (neonatal mortality rate [NMR], under-5 mortality rate [U5MR], maternal mortality ratio [MMR]) over the full MDG period – although to varying degrees and with mixed progress on achieving the MDGs, as shown in Fig. 3. (Data are presented in Additional file 1: Table B.2-2.) The prevalence of stunting among children under age 5 also declined (in case study countries with available data, see Additional file 1: Table B.2-2), with average annual rates of reduction of 4.3 % in Peru, between 1.7 and 2.5 % in Bangladesh, Ethiopia, Malawi and Tanzania, and 0.6 % in Niger.
Countdown to 2015 country case study progress to achieving MDGs 4 and 5 by income level. Data sources: MDG reports 2015, income level from the World Bank 2015. *i.e., % achievement of 66 % reduction for MDG 4 and 75 % reduction for MDG 5a
Figure 4 presents annual rates of change in the ten case study countries for neonatal, maternal, and childhood mortality, as well as total fertility rate, over the entire MDG period (1990–2015) and for each decade (1990–2000 and 2000–2015). The countries are presented – here and throughout – in descending order of U5MR reduction (1990–2015). The case study findings parallel those found across the 75 Countdown countries, where the largest reduction was observed in childhood mortality, and there were accelerated improvements post-2000 for many impact indicators. More details on the trends and findings for all of Countdown are available in the 2015 Countdown report [1].
Annual rate of reduction in impact indicators, in each Countdown to 2015 case study country, for the full MDG period (1990–2015), as well as for each decade (1990–2000 and 2000–2015). a Change in Neonatal & Under-5 Indicators. b Change in Total Fertility Rate. c Change in Maternal Mortality Ratio. Data sources: Analysis from UN Interagency Group for Child Mortality Estimation (IGME) in 2015; United Nations Population Division. World Population Prospects (WPP): The 2015 Revision. Total Fertility (TFR); WHO. 2015. Levels and Trends for Maternal Mortality: 1990 to 2015. Geneva: World Health Organization
In general, among the indicators studied, the Countdown case study countries achieved the most progress in reducing mortality among children aged 1–59 months: a 5.4 % average annual reduction since 1990, compared to 3.6 % for MMR and 3.1 % for NMR. Seven of the case study countries met, and even exceeded, MDG 4 to reduce their U5MR by two-thirds between 1990 and 2015: Bangladesh, China, Ethiopia, Malawi, Niger, Peru and Tanzania (Fig. 4a). These countries also reduced their NMR at approximately 3 % average annual reductions over this period which is more than their neighbours, but still half the rate of progress they made for child deaths after the neonatal period. In all countries the annual rate of reduction for NMR after the year 2000 was less than that for 1–59 month olds. In Pakistan neonatal deaths accounted for 56 % of under-5 deaths in 2015 and yet the annual rate of reduction for 1–59 month olds after the year 2000 is still 4.6 times higher than that for neonates. Progress in reducing mortality among neonates and children aged 1–59 months accelerated after the year 2000 in all case study countries except Afghanistan, Pakistan and Peru.
Fertility decline was slower post-2000 in many case study countries (Peru, Bangladesh, Tanzania, Kenya, and Pakistan) compared with before, and fertility increased in China after the year 2000 (Fig. 4b).
Although none of the case study countries met MDG 5, all reduced their MMR with six countries achieving >75 % progress toward the goal of 75 % reduction in MMR (with Bangladesh and Ethiopia achieving over 90 % progress) (Fig. 3). The most substantial annual reductions were seen in China, Ethiopia and Peru (approximately a 5.0 % annual rate of reduction), Afghanistan (4.8 %) and Bangladesh (4.6 %). Apart from Peru and China, all countries showed greater annual rates of reduction after the year 2000 (Fig. 4c).
Outcome - coverage
Figure 5 displays the most recent level of coverage for CoIA indicators at the time of publication, as a median value among all 75 Countdown countries and the national coverage for each case study country, and Fig. 6 displays change in these indicators since 1990 (for countries with available data). Countdown countries have attained rates of DTP3 (Diphtheria-tetanus-pertussis) immunisation that meet or exceed 70 % coverage, but this is the only indicator with such universally high coverage. Interventions during and after birth (e.g., skilled birth attendance [SBA] and postnatal care) have the largest ranges of coverage across the case study countries of 84 and 81 percentage points, respectively, followed by antenatal interventions (e.g., attendance at four or more antenatal visits has a range of 80 percentage points, and antiretrovirals during pregnancy and prevention of mother-to-child transmission of HIV have a range of 79 percentage points).
Most recent median national coverage (%) of selected Commission on Information and Accountability (CoIA) indicators in 75 Countdown to 2015 countries, with national coverage for case study countries. Grey bars indicate the median level of coverage per CoIA indicator across all 75 Countdown countries; dots represent the national level of coverage for each CoIA indicator per case study country
Change in coverage of select Commission on Information and Accountability (CoIA) indicators in Countdown to 2015 case study countries, over time. This figure includes only those case study countries with available data. Antenatal care and skilled birth attendance are reported among births during the 3 years preceding the survey
As shown in Fig. 6, all interventions saw increased coverage in the case study countries over this period – except attendance at four or more antenatal visits, which decreased in Kenya, Malawi and Tanzania (but increased in Bangladesh, Ethiopia, Niger and Peru); and exclusive breastfeeding in Ethiopia which declined over the period. Skilled birth attendance coverage more than tripled in Afghanistan, Bangladesh and Ethiopia; DTP3 vaccination increased by a similar degree in Afghanistan, Ethiopia, and Niger. Ethiopia also saw a large increase in demand satisfied for family planning (from 19 to 59 %), and Niger experienced a very large increase in the prevalence of exclusive breastfeeding of infants, from below 1 to 23 %. The exact level of coverage for each indicator is presented in Additional file 1: Table B.2-3.
Outcome - equity
The coverage statistics above represent all-population averages. A more nuanced story emerges when we examine how CoIA indicator coverage varied over time across socioeconomic groups. Figure 7 displays the equity gap, represented by the line that connects the coverage of each indicator for the poorest and richest groups in a country.
Coverage of select Commission on Information and Accountability (CoIA) indicators for Countdown to 2015 case study countries, in the poorest and richest wealth quintiles, over time (%). Figure 7 includes only those case study countries with available data. Antenatal care and skilled birth attendance are reported among births during the 3 years preceding the survey
Among the Countdown case study countries since the year 2000, Peru made the most significant progress in closing the equity gap on all indicators studied. It decreased the difference in coverage between poorest and richest groups by 32 percentage points for four or more antenatal visits, and 33 percentage points for SBA – though its equity gaps remain among the largest among case study countries for these indicators. Contrastingly, the equity gap increased for all indicators in Ethiopia over this period, by 23 percentage points for SBA, and nearly 10 percentage points for demand satisfied for family planning, attendance at four or more antenatal visits, and DTP3 immunisation. Both the poorest and richest quintiles in Ethiopia saw increased coverage of these interventions over the period – but richer groups saw greater improvements, which caused the equity gaps to increase (see Fig. 7).
Assessment of contributors to mortality change
The case study Lives Saved Tool (LiST) analysis results suggest ways in which changes in intervention coverage may be associated with reductions in childhood mortality. Figure 8 displays the results for LiST analyses conducted in five of the case study countries (Ethiopia, Malawi, Tanzania, Pakistan and Peru).
Estimated lives saved in Countdown to 2015 case study countries according to Lives Saved Tool (LIST) analyses which are associated with coverage of key interventions. a Children aged 1–59 months. b Newborns <1 month. c Children aged 0–59 months. All countries examine the year 2012 versus 2000 – except Ethiopia (*) which compares the year 2011 to 2000; and Pakistan (**) which compares 2012 to 2006. Negative numbers indicate a decrease in the coverage of an intervention over the period. LiST results from Malawi include averted deaths among children aged 0–59 months (#). Pregnancy and care includes obstetrics, essential newborn care, care of sick newborns and KMC. Nutrition includes breastfeeding, vitamin A supplementation, and measures to reduce wasting & stunting. Prevention and treatment of infections also includes pneumonia, malaria and diarrhoeal treatment, ITNs, vaccines and PMTCT. NB/ Deaths averted are only relating to those that can be explained by change in coverage of intervention
Increased coverage of two important interventions for preventing childhood infections – vaccines and insecticide treated nets (ITNs, to prevent malaria transmission from mosquitoes) – was estimated to be associated with many averted child deaths in the case study countries. When only changes in mortality after the neonatal period was examined (Fig. 8a), increased coverage of vaccines and ITNs were estimated to be associated with 31 % of the lesser deaths in 2011 versus 2000 in Ethiopia, and 28 % of the fewer post-neonatal and childhood deaths in Pakistan for the year 2012 versus 2006 – and as high as 64 % in Tanzania, and 72 % in Peru, for 2012 versus 2000. These gains in Pakistan and Peru were all due to vaccines, since there is low malaria transmission in these settings. Additionally, increased treatment of infections was associated with approximately 10 % of the averted post-neonatal childhood deaths over this period in Ethiopia and Tanzania, but only 2 and 4 % in Pakistan and Peru, respectively.
Nutrition improvements, i.e., reduced stunting and wasting, increased coverage of vitamin A supplementation, and improved breastfeeding, were estimated to be associated with 47 % of the decline in post-neonatal child mortality in Ethiopia in 2011 versus 2000, and 24 % in Peru for 2012 versus 2000 (Fig. 8a).
Among neonatal deaths (Fig. 8b), increased clean birth practices, labour and delivery management, and postnatal care for all neonates and thermal and kangaroo mother care, were estimated to be associated with 35 % of the fewer neonatal deaths in Peru in 2012 versus 2000, 33 % of the reductions in Tanzania over this period, and 44 % in Pakistan for 2012 versus 2006.
Assessment of changes in social and economic factors
The socioeconomic and development context in the case study countries changed substantially between 1990 and 2013 (detailed information in Additional file 1: Table B.2-4), and change was heterogeneous across the case study countries. For example, Ethiopia saw large improvements in access to clean water and improved sanitation, with the most substantial gains occurring during the 1990s: between 1990 and 1999, access to improved sanitation increased by 13.3 % per year and by 7.5 % between 2000 and 2013, and access to safe water increased by 7.8 % per year during 1990–1999 as compared to 4.1 % for the 2000–2013 period. Peru began the MDG era with relatively high levels across the key socioeconomic factors analysed, such as per-capita gross national income (approximately quadruple the average value from the other case study countries, at over 3000 USD in 1990), female literacy (80 % and above throughout this period), urbanisation (69 % of the population in 1990), and access to safe water and sanitation (75 and 54 % in 1990, respectively).
Several case studies highlighted examples of how political commitment and strong leadership aided progress towards MDGs 4 and 5. For example, Tanzania has had strong and consistent political stability for decades and has seen a recent proliferation of RMNCH policies resulting in the development of an integrated and comprehensive "One Plan" [11]. Peru's leaders demonstrated strong and continued political commitment to improving the health of mothers and children throughout the MDG era, allowing Peru to sustain macro policies despite changes in leadership, resulting in long-term pro-poor health policies for RMNCH [10]. Similarly, Ethiopia's government adopted and backed a comprehensive 20-year health sector strategic plan in the 1990s, including the introduction of its Health Extension Programme which has been singled out as a successful step for improving healthcare delivery at the community level [7]. Malawi's government also demonstrated strong formal leadership through the early adoption of evidence-based policies for child survival [8]. Afghanistan signed the Millennium Declaration in 2004, a demonstration of political commitment, despite ongoing instability [6]. In contrast, Pakistan has yet to see sustained political commitment or support for maternal and child health [9].
A lack of political commitment was cited by the case study teams as a key factor in explaining the relative inattention to newborn health until more recently, compared to post-neonatal child health. Newborn health was not on the global agenda until the early 2000s when the large and growing percentage of child deaths occurring in the neonatal period, and the preventable causes of neonatal deaths were highlighted in two Lancet series [23, 24]. Increased awareness of the evidence led to increased political attention, and many of the case study countries introduced policies and programmes specifically targeted to newborns; for example, a National Child Survival Strategy was introduced in Ethiopia in 2005 to address neonatal and child mortality [7], and Tanzania conducted a Situational Analysis in 2009 to specifically introduce strategies for reducing newborn mortality [11]. Malawi's attention to newborn survival also intensified after 2005 with a new roadmap to reduce maternal and neonatal mortality [8], and the Peru case study specifically discussed how the Lancet series informed its newborn policies, which now include national scale-up of neonatal care [10].
Health system governance structures were also cited as affecting RMNCH policy and programme adoption. Three case study countries introduced decentralisation to improve intervention coverage for all population groups. The case studies from Peru and Ethiopia mentioned how decentralisation has increased the active participation of local and regional governments in the design and implementation of RMNCH programmes [7, 10], while in Tanzania, decentralisation has provided financial resources for health programmes to districts since 2000 [11]. However, health system decentralisation can have mixed results, as in Peru where the Ministry of Health saw reduced capacity to perform its functions outside of the capital city [25].
Health system financing
Most case study countries have seen increased financial flows to RMNCH, with the exception of Pakistan, where the total expenditure on health (as a percentage of the gross domestic product) has remained stagnant [19]. However, overall expenditures remain low in relation to international benchmarks for almost all the Countdown case study countries [26, 27], and this is especially true for resources mobilised domestically.
Peru, a middle-income country, experienced considerable economic growth over the MDG period, which translated into more resources available for effective intervention implementation and scale-up across the CoC for RMNCH [10]. The other case study countries are lower-income countries and have been more dependent upon external funding sources (Malawi, Tanzania, Ethiopia, and Afghanistan), which overall increased over the study period [28].
Health financing across the CoC is variable among the case study countries in terms of both level and functions supported; findings on these trends in financing are discussed in detail elsewhere in this supplement [28]. Maternal and neonatal health have generally received less funding than child health, and several case studies – including Afghanistan, Ethiopia, Malawi and Tanzania – attributed this to donors' emphasis on vertical and disease-specific programmes: high impact interventions for child health (e.g., immunisation, ITNs and Integrated Management of Childhood Illness (IMCI)) have received substantial external financing [6–8, 11].
Four case study countries cited shortages in skilled human resources, including inequitable geographic distribution of available health workers, as a major bottleneck to MDG progress (Ethiopia, Malawi, Pakistan, Tanzania). The poorest areas of Afghanistan have seen the smallest growth in health worker cadres, and a multivariable analysis found that low nearby availability of midwives was associated with lower likelihood of skilled birth attendance and of facility birth [11]. There have been some innovative approaches to expand the numbers and roles of lower level workers. For example, Ethiopia developed the Health Extension Programme to address increasing demand for primary health care [7], and Malawi introduced an emergency human resources plan, which increased the number of health care workers by 53 % between 2004 and 2010, including a more than two-fold increase in Health Surveillance Assistants [8] – although both case studies mentioned concerns about quality of health workers.
Medicines and commodities
Stock-outs of medicines and supplies were commonly mentioned in the case studies as hindering delivery of high quality, effective services. For example, Pakistan reported that only 37 % of basic health units have all critical medicines in stock, including modern contraceptive methods [19]; and the Tanzania case study found geographic disparities in stock-outs of family planning commodities [11]. Several case study countries have worked to increase access to medicines and commodities. Strengthening pharmaceutical and medical supply availability is a priority area in Ethiopia's Health Sector Development Programme [7]; and Malawi established a Central Medical Stores Trust to improve the pharmaceutical supply chain, although stock-outs are reportedly still common [8].
Health service delivery, quality, and utilisation
Several case studies noted a shift after the year 2000 in programme focus, from high impact "vertical" interventions, such as the Expanded Programme on Immunisation (EPI) to the introduction of more integrated approaches to RMNCH services such as IMCI, ICCM and other community-based health programs. An example of the latter is Afghanistan's community-based health care and community midwife programmes, to which the case study attributes Afghanistan's rapid recent increases in SBA and antenatal care [6]. Similarly the HEP and construction of health posts were cited by the Ethiopia case study as associated with remarkable gains in primary health care coverage [7].
Additionally, Peru has introduced health reform initiatives, with a targeted multi-sectoral approach and a focus on women and children in poor areas – and the case study from Peru found that this was associated with improved access and utilisation of health services, such as antenatal care and skilled birth attendance, as well as a reduced equity gap between the rich and the poor and between urban and rural areas [10].
Several case studies illustrate that policy adoption alone is insufficient if not followed by effective policy and programme implementation. For example, Tanzania developed a "One Plan" to consolidate the fast-growing landscape of domestic policies and strategies around RMNCH – but it lacked a clear operational structure and costing system, and therefore was never fully implemented [11, 29]. Case studies from Ethiopia, Malawi and Tanzania noted that such implementation failures were found to be particularly evident for maternal and newborn health, as these programmes which may require more complex implementation than child health interventions, often received less consistent and effective execution, despite strong political commitment [7, 8, 11].
Poor health service quality was often cited as a barrier to progress, particularly for maternal and newborn health. As discussed above, although several countries have expanded their health workforce (e.g., Malawi, Ethiopia, and Afghanistan), these health workers may lack the skills to manage complicated conditions [6–8]. Likewise, case studies from Ethiopia and Peru discussed how the number of health facilities has increased, but poor quality may hinder outcome improvements [7, 10].
Country context
One common contextual factor driving progress discussed in the case studies was general economic growth leading to poverty reduction. All of the case study countries saw economic growth over this period, which has contributed to development, but widespread poverty and limited resources persist in many countries.
Political stability was also discussed by the case study teams as central to MDG progress. Tanzania experienced decades of political stability, permitting its government to promote the MDGs [11]. On the other hand, Afghanistan has long experienced insecurity and conflict, but has achieved progress in the past decade, particularly enabled by external donor support and the reconstruction process [6]. Ethiopia, which had previously been affected by widespread and protracted conflicts, has seen greater stability under the new government established in 1991; its new constitution (ratified in 1994) prioritises principles of democracy and equity, and created a paradigm shift in governance and policy-making including in health [7]. Peru's transition to democracy during the early 2000s encouraged broad participation in policy decision-making, including active participation of civil society – which the case study described as instrumental to fostering political will and commitment to RMNCH at all levels, and may have facilitated Peru's outstanding performance on the MDGs despite some political and economic unrest before this period [10].
Country teams such as Ethiopia and Malawi drew linkages between gains in child health and improvements in food availability and consumption. Against its history of conflicts, poverty and food crises, for example, Ethiopia made substantial efforts to address nutrition, agricultural productivity, and to introduce a safety net against droughts [7]. In Malawi, coverage gains were achieved in community-based nutrition interventions in the mid-2000s and the country experienced an increase in food security [8].
The Countdown country case studies used mixed methods to comprehensively assess why and how selected countries in Asia, Latin America and sub-Saharan Africa achieved or failed to meet MDGs 4 and 5. A standard framework and methodology were applied for each case study country, which enabled us to systematically review findings and identify key lessons learned.
Seven of the 10 case study countries (China, Peru, Malawi, Bangladesh, Ethiopia, Niger and Tanzania) achieved MDG 4 to reduce childhood mortality, with particular gains seen after the year 2000, and in deaths between the ages of 1 and 59 months. Neonatal mortality gained attention from the mid-2000s, and improved more slowly. There was also progress, although to a slightly lesser degree, toward reducing maternal mortality (MDG 5a), particularly in Afghanistan, Bangladesh, China and Ethiopia. These findings are similar to those reported for the full Countdown project [1] and elsewhere in the literature [6, 8].
Success in scaling up interventions delivered in communities and via primary health care system
The case study countries were most successful in scaling up interventions that can be delivered via the primary health care system and in communities, especially child health interventions. There has been widespread implementation of high-impact interventions that can be administered via low levels of the health system, especially for child health. A prime example of this is childhood vaccinations, which began decades ago with the EPI programme, now has broad global support, including substantial financing, and a robust evidence base [30, 31], and includes newer vaccines for pneumococcal disease, rotavirus, and Haemophilus influenzae type B (Hib). The LiST analyses suggest that the scale-up of immunisations, especially these newer vaccines, may have been associated with many of the post-neonatal infant and childhood lives saved in the case study countries by the year 2012.
The Countdown case studies suggest mechanisms for improving equity, such as in Peru, where the country's pro-poor and targeted implementation strategy of childhood immunisation increased equity in health outcomes. The Pakistan case study highlighted the potential riskiness of tightly focusing on a single intervention: the recent emphasis on polio eradication was cited as a detriment to uptake of routine childhood immunisations [19].
The case study countries' initiatives to strengthen lower levels of the health system, including community-based programmes and strengthening cadres of lower-level health workers, were also seen as important for improving access to key interventions. For example, although not specifically analysed here, the Niger case study discussed how investments into universal primary health care, including health system strengthening and introducing a new cadre of community health workers, were key factors in the country's improvement in child survival [4].
Although there is robust evidence on the importance of meeting the need for family planning [32, 33], which can often be achieved via the primary health care system or at the community level, this was generally not explored in the case studies – with the exception of the Tanzania case study, which noted the highly variable commitment to, and implementation of, reproductive health programmes since the 1980s [11].
Variable and lesser increases in coverage of interventions that must be delivered through middle- and higher-level facilities
Interventions delivered via higher-tiered facilities as part of a functioning health system also have persisting equity gaps and have obtained less external support. A key example of this is SBA, which had the most variable level of coverage among all the indicators, as well as the largest equity gaps, which echoes global Countdown findings [1].
The case studies showed that supportive programmes and policies arrived later for maternal and neonatal interventions, corresponding to a global delay in attention for these issues [34]. This may reflect the lack of clear, universally agreed-upon strategies for maternal and neonatal care, despite repeated proposals and an evidence base on effective interventions [35–40]. This lack of a global consensus saw a parallel in the country case studies – which, for example, reported a variety of approaches to improving neonatal health, from scaling up neonatal resuscitation and Kangaroo Mother Care in Tanzania, to implementing a community-based newborn care model in Ethiopia and Malawi.
The case study results are also consistent with the evidence base showing that there may be a limit to how much a country's U5MR may be lowered if its NMR remains high. Continued improvements in childhood survival may also require more complex interventions, e.g., treatment coverage for pneumonia and diarrhoeal disease as well as improved nutrition programmes, and these lagged over the study period in case study countries. [1]. The global health community must emphasise further improvements in these areas.
Health system constraints, including health worker shortages, were identified by the case study countries as a major barrier to achieving the MDGs, as has been reported elsewhere in the literature [41], particularly for decreasing maternal and neonatal mortality [13, 42, 43]. Although several of the case studies cited poor quality of care as a potential limiting factor to progress [44–47], this is difficult to quantify and was not explored empirically in these case studies. This is an area where future research is clearly needed.
Governments, in partnership with the donor community, must continue focusing on health system strengthening. The Sustainable Development Goals' framework promotes the achievement of universal health care, which requires emphasis on improving health systems, particularly in countries faced with an unfinished agenda of high maternal and child mortality coupled with increases in non-communicable diseases.
Political, economic and social factors contributed to MDG progress
Political, social and economic factors enabled progress in RMNCH, though the extent is difficult to assess and quantify. These findings are consistent with the emphasis on multi-sectoral approaches to addressing mortality and development in the new Sustainable Development Goals [48].
It is clear from the literature that social and economic development, as well as political context and shifts across non-health sectors, influenced health outcomes and affected the implementation of health policies and programmes including the MDGs [49–51]. The case study countries experienced many political, economic and social changes during the MDG era, and nearly all the case studies discussed the importance of context in influencing progress. The Bangladesh case study, although not included in this comparative content analysis, also showed both health and non-health sector factors (such as improvements in household wealth and women's education) were crucially important in explaining reductions in maternal mortality [5].
The case studies indicate that changes in both context and coverage contribute to improved maternal, newborn and child survival. However, further research is needed to precisely attribute their relative contributions in each setting. For example, the case study LiST analyses did not entirely predict the actual survival improvements seen since 2000: it accounted for 80 % of the reported mortality reduction in Malawi over this period, 73 % in Peru, 51 % in Ethiopia, and 39 % in Tanzania. This may be because LiST analyses do not capture all coverage-related changes that may be relevant for mortality decline. They also do not model the role of non-intervention factors, such as infrastructure, economic development, or changes in social and demographic determinants such as education [52, 53] – which are likely also important for mortality reduction.
An important example of the complex interplay of policies and context with health outcomes is childhood nutritional status. Several case study countries with good progress on stunting took multi-sectoral approaches to addressing this problem, such as introducing reforms in the agricultural sector coupled with nutrition-specific programmes delivered through the health sector, as well as large gains in the coverage of improved water and sanitation. The Niger case study also hypothesised that its multipronged approach to addressing under-nutrition – including both ongoing and emergency services – was an important factor in reducing childhood mortality [4]. Effective mechanisms to reduce under-nutrition are crucially important, as it is estimated that this is the cause of 45 % of all deaths among children under age 5 [54].
Measurement is key for effective implementation and monitoring of global initiatives
These results underscore the importance of measurement for the effective implementation and monitoring of global initiatives like the MDGs and now, going forward, the Sustainable Development Goals.
The Countdown initiative, including the case study analyses, have emphasised the centrality of high-quality data for evaluating progress, including identifying lessons learned and remaining gaps, and for programme monitoring purposes. Although Countdown and others have helped generate momentum for improved measurement and accountability globally and in some countries, there is still a long way to go. Data collection has increased for many indicators [1], but remains a challenge in many countries, particularly those that lack vital registration systems; only one case study country (Peru) contributed vital registry data to the latest WHO maternal mortality estimate. Although some interventions may be comparatively well-monitored, such as immunisations (for which data systems often exist to track antigen-specific coverage at a sub-national level, as well as information on vaccine financing, supply chain issues such as stock-outs, etc.), other domains are less well understood. An important example is neonatal mortality, which is inconsistently defined and measured across settings (including how intrapartum stillbirths are classified, as well as when and how births are recorded), when it is measured at all.
Reliable, frequent and timely data on the coverage and equity of interventions, and on health outcomes, can inform policy adoption and implementation of programmes. Regional- or district-level information can be used to guide implementation, and to measure progress [55]. Such data can also be used to inform research endeavours, such as the LiST analyses included here, which themselves can inform policy-making and priority-setting. Additionally, mixed methods research approaches, like the Countdown case studies, are an important means for going beyond summary indicators, and assessing the "how" and "why" of progress (or not). Such studies should continue to be undertaken during the Sustainable Development Goals era.
Information availability and data democratisation can enable the engagement of a wide range of stakeholders in discussions about health policies and programmes. The case studies demonstrate that data collection, analysis and synthesis are only the first steps in promoting data use by decision-makers and advocates for action. Some of the case study countries, such as Tanzania, engaged local stakeholders in discussions about the data and progress toward MDGs 4 and 5, which helped stimulate local ownership of the results. More work is needed on refining the Countdown case study model so that dissemination efforts lead to greater uptake of findings for programming and planning purposes. Additionally, more work remains to be done on how to incorporate the private sector into case study analyses, to develop a fuller picture of factors driving progress.
Recent discussions have emphasised the importance of data in sustained global and national accountability in achieving future gains in RMNCH, in health more broadly, and in the context of achieving universal health coverage [56–58].
The Countdown case study portfolio has several strengths, including geographic representation from countries in Africa, Asia and South America; a standard evaluation framework, with a mixed methods analysis approach to attempt to capture the complex factors driving progress; and national capacity-building and engagement of a range of stakeholders in the case study process. This last point in particular distinguishes the Countdown case study process as offering a unique, locally-driven perspective on important RMNCH topics.
There were a number of limitations to our study that should be noted. First, there were a small number of case studies conducted and there may have been case selection bias, since the countries were selected on a number of factors that may be correlated with degrees of change, including data availability and in-country capacity to undertake the research. Secondly since the case studies were largely focused on post-neonatal child health outcomes, the content analysis presented in this cross-cutting paper could not robustly examine reproductive, maternal, neonatal, nor adolescent health. This underscores the importance of increasing attention to these parts of the continuum of care, and perhaps more thoroughly integrating research and practice regarding the more neglected areas of reproductive, adolescent, and neonatal health with the generally more successful maternal and child health issues. We were therefore limited in our ability to explore certain hypotheses – particularly since the case study countries were not selected as representative of certain outcomes (as has been done in other research, such as the Success Factors case studies [59]) so formed a non-systematically heterogeneous dataset. Thirdly, the content analyses were limited to materials made available from the second phase country teams. We aimed to minimise biases by having two investigators separately conduct the content analysis and by vetting our conclusions with the case study team members. However, we note that there were limited data for health information systems, and evaluation of political, governance and leadership aspects, which are crucial to understanding progress and require further analyses [55]. Lastly, the measurement of many of the quantitative indicators – including mortality outcomes, which are modelled estimates usually based on household-level nationally representative surveys, as well as coverage and equity data, which are based on nationally representative DHS surveys – face limitations such as small sample size and challenges with estimation procedures; implications of this for LiST analysis results are discussed at length elsewhere [53].
The Countdown case studies present a complex picture of progress toward MDGs 4 and 5 (Table 1). The results indicate that achieving mortality change at a population level is not merely a technical process of adopting policies or administering programmes. Rather, an interchange of factors which determines intervention coverage and equity, which subsequently affect health outcomes and impact.
Table 1 Key messages
This comparison across the case study countries, as well as findings from the Countdown report looking across all 75 priority countries [1], indicate that substantial progress was achieved during the MDG era in the highest burden countries – particularly for interventions that had greater global buy-in and financing. With more focus (attention and funding) came greater coverage and equity, which suggests a clear future path forward: we must continue to implement these approaches that have so far been successful and also must increase attention to other interventions and to underlying health system strengthening, including hospital care for sick newborns, for more effective, equitable and efficient policy and programme implementation. Improvements in sectors outside of health such as in agriculture and education are also critical.
The case studies were developed by country-based researchers and policymakers, supported by the Countdown technical working groups. Many case studies had strong local buy-in and some have resulted in real change at the national level. An example of this can be seen in Tanzania, where the Countdown case study results were launched by the President and used to develop the Sharpened One Plan, which aimed to accelerate reductions in the NMR, U5MR and MMR [11]. This reflects an important shift towards a research model that emphasises capacity building and engagement of stakeholders at the country level. Such exercises need to be replicated, and improved measurement should be a key priority in future efforts.
Data show that maternal and child mortality reduction accelerated over the last five years. We are at a critical juncture as the world moves into the Sustainable Development Goals era, and must commit to doing more – not less to finish the unfinished agenda of RMNCH. The Countdown case studies demonstrated that focused attention, financing and effective implementation can make a real impact on improving equitable intervention coverage and saving lives. They also underscore the importance of progress monitoring, which depends on the availability of reliable data, as essential for accountability. In the years ahead, the global community must sufficiently invest in data systems and other health system strengthening efforts to improve accessibility of high quality care while also addressing the underlying social and political determinants of health. We also must gain an improved understanding of how to improve outcomes for special populations – including adolescents, and groups affected by conflict and other humanitarian emergencies; these were largely not explored by the Countdown case studies but should be critical priorities over the coming decades. Compared to the MDG era, an even greater level of ambition, investment, measurement and accountability is required to address the "survive, thrive and transform" agenda in the new Global Strategy for Women's, Children's and Adolescents' Health [60].
CoC, continuum of care; CoIA, United Nations Commission on Information and Accountability for Women's and Children's Health; Countdown, countdown to 2015; DTP3, diphtheria-tetanus-pertussis immunisation; EPI, Expanded Programme on Immunisation; Hib, Haemophilus influenzae type B immunisation; ICCM, Integrated Community Case Management; IMCI, Integrated Management of Childhood Illness; ITNs, insecticide treated nets; LiST, Lives Saved Tool; MDG, Millennium Development Goal; MMR, maternal mortality ratio; NMR, neonatal mortality rate; RMNCH, reproductive, maternal, newborn and child health; SBA, skilled birth attendance; U5MR, under-5 mortality rate; WHO, World Health Organisation
Although stillbirths are an important impact measure, they were generally not investigated by the case study teams, so are not discussed in this paper.
The Pakistan analysis was still underway at the time of this publication so only minimal information could be included; similarly, China and Kenya were not included because their case study analyses were incomplete at the time of publication.
Victora CG, Requejo JH, Barros AJD, Berman P, Bhutta Z, Boerma T, Chopra M, de Francisco A, Daelmans B, Hazel E, et al. Countdown to 2015: a decade of tracking progress for maternal, newborn, and child survival. Lancet. 2015;387(10032):2049–59.
Requejo JH, Bhutta ZA. The post-2015 agenda: staying the course in maternal and child survival. Arch Dis Child. 2015;100 Suppl 1:S76–81.
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The authors thank the members of the Countdown Scientific Review Group, for their involvement in the design of the case study model, and for providing support to the case study teams. Additionally, we acknowledge and appreciate assistance from Lois Park and the IIP-JHU Countdown coverage team for Fig. 5; Maria Clara Restrepo and the International Center for Equity in Health for Fig. 7; and Shefali Oza for Additional file 1: Table B.2-4. We also thank the country case study teams for all their valuable research, and for their involvement and contributions to this cross-cutting analysis. We are grateful to Robert Black for providing valuable feedback on the draft manuscript.
All costs for the writing and publication of this paper were provided through a sub-grant from the U.S. Fund for UNICEF under the Countdown to 2015 for Maternal, Newborn and Child Survival grant from the Bill & Melinda Gates Foundation, and from the Government of Canada, Foreign Affairs, Trade and Development. This article has been published as part of BMC Public Health Volume 16 Supplement 2, 2016: Countdown to 2015 country case studies: analysing progress towards maternal and child survival in the Millennium Development Goal era. The full contents of the supplement are available online at http://bmcpublichealth.biomedcentral.com/articles/supplements/volume-16-supplement-2.
All costs for the writing and publication of this paper were provided through a sub-grant from theU.S. Fund for UNICEF under the Countdown to 2015 for Maternal, Newborn and Child Survival grant from the Bill & Melinda Gates Foundation, and from the Government of Canada, Foreign Affairs, Trade and Development.
All data used for these analyses are publicly available [6–12, 14–18].
CM & HO participated in research design for the analyses presented here and in the process of drafting and revising the manuscript. CM conducted and led the quantitative data analysis and discussion. HO led the qualitative data analysis and background to the case studies. NSS, CKN and JR participated in research design for the analyses presented here, jointly assisted with the qualitative data analyses, and contributed to drafting and revising the manuscript. All authors provided critical input and insights into the development and writing of the article. All authors read and approved the final manuscript. JEL and PB led the conceptualisation of the Countdown country case study project, led the research design for the analyses presented here, and oversaw the development of the manuscript.
Countdown Case Study Collaborative Group: Afghanistan (Nadia Askeer, Zulfiqar Bhutta, Ahmed Salehi); China (Zhou Hong, Carine Ronsmans, Neha Singh, Gao Yanqiu); Ethiopia (Mekonnen Tadesse, Hillena Kebede, Carlyn Mann, Neha Singh, Jenny Ruducha); Kenya (Zulfiqar Bhutta, Anthony Ngugi, Emily Keats, William Macharia, Nirmala Ravishankar, Neha Singh, John Tole); Malawi (Jennifer Bryce, Tim Colbourn, Bernadette Daelmans, Mercy Kanyuka, Humphreys Nsona); Pakistan (Nadia Askeer, Zulfiqar Bhutta, Zaid Bhatti, Arjumand Rizvi); Peru (Jessica Niño de Guzman, Luis Huicho, Cesar Victora) & Tanzania (Hoviyeh Afnan-Holmes, Theopista John, Joy Lawn, Moke Magoma, Georgina Msemo)
University of California Fielding School of Public Health, Los Angeles, CA, 90095, USA
Corrina Moucheraud
Centre for Maternal, Adolescent, Reproductive & Child Health, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
, Neha S. Singh
& Joy E. Lawn
Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
Courtney Kuonin Ng
& Peter Berman
Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
Jennifer Requejo
Search for Corrina Moucheraud in:
Search for Helen Owen in:
Search for Neha S. Singh in:
Search for Courtney Kuonin Ng in:
Search for Jennifer Requejo in:
Search for Joy E. Lawn in:
Search for Peter Berman in:
Ahmed Salehi
, Zhou Hong
, Carine Ronsmans
, Gao Yanqiu
, Hillena Kebede
, Carlyn Mann
, Jenny Ruducha
, Mekonnen Tadesse
, Anthony Ngugi
, Emily Keats
, William Macharia
, Nirmala Ravishankar
, Neha Singh
, John Tole
, Jennifer Bryce
, Tim Colbourn
, Bernadette Daelmans
, Mercy Kanyuka
, Humphreys Nsona
, Nadia Askeer
, Zulfiqar Bhutta
, Zaid Bhatti
, Arjumand Rizvi
, Jessica Niño de Guzman
, Luis Huicho
, Cesar Victora
, Hoviyeh Afnan-Holmes
, Theopista John
, Joy Lawn
, Moke Magoma
& Georgina Msemo
Correspondence to Corrina Moucheraud.
Additional file
Additional material. (DOCX 112 kb)
Health finance

redpajama_set_name: RedPajamaCommonCrawl


Celtic manager Gordon Strachan declined to offer sympathy to his beleaguered Rangers counterpart Paul Le Guen.
The Hoops have stormed ahead in the Bank of Scotland Premier League and are already 15 points clear of the Ibrox men after 13 games. And Rangers' CIS Insurance Cup defeat by St Johnstone on Wednesday brought such an avalanche of criticism on the former Lyon manager's head that chairman David Murray was driven to offer his support at the traditional Friday pre-match press conference.
He added: "I empathise with every manager. Every Saturday, whether it be Yeovil or anywhere, when I see a manager who is hurting, I empathise with them. That's the way I am.
"I said if I wanted to speak to Alex I would lift up the phone and speak to him and it would be the same to any manager and I have done it regularly.


But at the same time it is welcoming and soothing. You will not be judged. The reason one eye is closed is that a strand of hair, not just an eyelash, had wrapped itself around my eye. Not like, a little bit around, but all the way around my eyeball to where it vanished into the recesses of my skull on both the top and the bottom of the eye. removing that while vomiting and shitting into a togo container and spitting into a cup and sweating in the 110 degree heat was my final passage out of the womb. What happens after this is all my fault. No one else is to blame.


text:
package expression.generic;

public class MyIntegerOverflow extends MyAbstractNumber<Integer> {

    public Integer add(Integer x, Integer y) throws EvaluateException{
        int res = x + y;
        if (((res ^ x) & (res ^ y)) < 0) {
            throw new EvaluateException("Overflow");
        }
        return res;
    }

    public Integer multiply(Integer x, Integer y) throws EvaluateException {
        int res = x * y;
        if ((x | y) >> 15 != 0) {
            if (((y != 0) && (res / y != x)) || (x == Integer.MIN_VALUE && y == -1) || (x == -1 && y == Integer.MIN_VALUE)) {
                throw new EvaluateException("Overflow");
            }
        }
        return res;
    }

    public Integer divide(Integer x, Integer y) throws EvaluateException {
        if (x == Integer.MIN_VALUE && y == -1) {
            throw new EvaluateException("Overflow");
        }
        if (y == 0) {
            throw new EvaluateException("Division by zero");
        }
        return x / y;
    }

    public Integer negative(Integer x) throws EvaluateException {
        if (x == Integer.MIN_VALUE) {
            throw new EvaluateException("Overflow");
        }
        return -x;
    }

    public Integer abs(Integer x) throws EvaluateException {
        if (x == Integer.MIN_VALUE) {
            throw new EvaluateException("Overflow");
        }
        if (x >= 0) {
            return x;
        } else {
            return -x;
        }
    }

    public Integer makeFromInt(int x) throws EvaluateException {
        return x;
    }
}

redpajama_set_name: RedPajamaGithub


A delicious and interested recipe from Chef Melissa Cookston.
Combine all the ingredients in a small mixing bowl and stir by hand until well incorporated. Store in an airtight container for up to 2 months.
1) To make the turkey, prepare a smoker to cook at 250°f with apple or another fruitwood.
2) Rinse the turkey and pat it dry. brush it with the olive oil, then generously season all surfaces of the turkey with the pepper poultry rub.
3) Place a strip of aluminum foil just larger than the turkey in the smoker, lay the herbs on it, and place the turkey, breast-bone-side down, on top of the herbs.
4) Smoke for 3 hours, until the internal temperature in the thickest part of the breast reaches 165°f.
5) Remove the turkey from the smoker (including the foil with the herbs) and set it on a larger piece of foil. Wrap tightly for 20 to 30 minutes to rest.
6) Wearing gloves, remove the turkey from the foil and fillet the breasts from the bones. Slice thinly for sandwiches.
1) Spray a waffle iron with nonstick cooking spray and preheat it.
2) In a large bowl, mix the flour, kosher salt, pepper, rosemary, baking powder, and sugar. In a separate bowl, whisk the eggs, then stir in the milk and melted butter.
3) Add the egg mixture to the dry ingredients and stir until all the flour is incorporated. Ladle the batter into the waffle iron. cook until crisp, then remove.
4) Sprinkle the top waffle bun with flaked sea salt. repeat with the remaining batter.
1) Using a mandoline, slice the sweet potatoes very thinly and set aside.
2) In a large frying pan, heat the oil to 350°f. lay the chips in the oil, but do not overcrowd.
3) Cook for 2 to 3 minutes, then turn the chips over and cook until crisp but not burned, about 2 to 3 minutes. Transfer to a paper-towel-lined plate to drain and cool.
4) Sprinkle with the rosemary, smoked sea salt, and black pepper.


text:
Easily input tabular data using only your keyboard.

# Key Features
 - Optional minimum and/or maximum number of rows;
 - Configurable markup and tabstop for each column;
 - Use cursor keys, Tab, Shift+Tab to navigate across all the columns and rows;
 - Data can be imported/exported from/to Json;
 - Strong event driven support;
 - Rows can be added or removed asynchronously after an ellapsed time. Ideal for CSS3 animations;
 - Small footprint.

# Installation

You can install from [npm](https://www.npmjs.com/):
````bash
npm install jquery.rsLiteGrid --save
````
or directly from git:
````javascript
<script src="http://rawgit.com/ruisoftware/jquery-rsLiteGrid/master/src/jquery.rsLiteGrid.js"></script>
````
or you can download the Zip archive from github, clone or fork this repository and include `jquery.rsLiteGrid.js` from your local machine.

You also need to download jQuery. In the example below, jQuery is downloaded from Google cdn.

# Usage
````javascript
<!doctype html>
<html>
<head>
  <title>jquery-rsLiteGrid plug-in</title>
  <script src="https://ajax.googleapis.com/ajax/libs/jquery/2.1.4/jquery.min.js"></script>
  <script src="http://rawgit.com/ruisoftware/jquery-rsLiteGrid/master/src/jquery.rsLiteGrid.js"></script>
  <script>
    $(document).ready(function () {
      $('table').rsLiteGrid();
    });
  </script>
</head>
<body>
	<table></table>
<body>
</html>
`````
This creates a very simple 1x1 table.

You can see a more complete example [here](http://codepen.io/ruisoftware/pen/QNQjoB?editors=1010 "on CodePen") on CodePen or on the [test.html](http://rawgit.com/ruisoftware/jquery-rsLiteGrid/master/src/demo/test.html).

By default, a new row is appended automatically when you modify the last row. Obviously, you can disable this and add rows programatically.

# License
This project is licensed under the terms of the [MIT license](https://opensource.org/licenses/mit-license.php)

# Bug Reports & Feature Requests
Please use the [issue tracker](https://github.com/ruisoftware/jquery-rsLiteGrid/issues) to report any bugs or file feature requests.

# Contributing
Please refer to the [Contribution page](https://github.com/ruisoftware/jquery-rsLiteGrid/blob/master/CONTRIBUTING.md) from more information.


A view of the Las Vegas Strip in October from the Strip's south end.
Published Tuesday, Jan. 12, 2010 | 7:43 a.m.
Updated Tuesday, Jan. 12, 2010 | 1:01 p.m.
CARSON CITY – Reversing a 22-month decline, the casinos on the Las Vegas Strip registered an 8.2 percent increase in gaming win in November.
The increase was paced by a 136.2 percent jump in gross win at the 191 baccarat games, the seventh-straight month of an increase in this category. Winnings on sports parlay cards rose 79.7 percent as the pro and college football season was in full swing.
This increase compares with a soft November 2008, when the win on the Strip fell by 14 percent, says Frank Streshley, chief of tax and licensing for the state Gaming Control Board.
The last monthly increase reported by Strip casinos was in December 2007 at 0.8 percent.
The state Gaming Control Board reported today that clubs statewide had a 4.3 percent increase in their gross win, computed before expenses and taxes. It also ended a 22-month decline. The 322 non-restricted casinos had $873.1 million in win.
The state collected $57 million in taxes based on that win, up 28.23 percent from the same month of 2008. The "collections were off the roof," said Streshley, adding the casinos collected some of the credit previously extended to players.
Part of the increase on the Strip came from the Pacquiao-Cotto fight at the MGM in the middle of the month, said Streshley. That sparked high-end play.
Strong win numbers were posted in North Las Vegas, up 20.7 percent; Boulder Strip had an increase of 18.9 percent and the balance of Clark County had an increase of 18.9 percent, ending 13 months of declining revenues for that sector.
The board reported the Strip casinos won $473.8 million during the month. But for the three-month period ending Nov. 30, the gross win was down 2.1 percent.
Some places in Clark County didn't do as well in November. For the 18th straight month, downtown Las Vegas casinos were down, 1.2 percent; casinos in Laughlin reported a 5.5 percent decline in revenue, the 24th consecutive month of a decline, and Mesquite casinos registered a 15.5 percent decline in gross win, the 10th straight month of a drop.
After 19 straight months of declines, the casinos on the Strip registered a 4 percent increase in win from the 21 games in November. Winnings from craps tables fell 32.4 percent. Roulette win increased 12.3 percent but slot win fell by 3.7 percent for the 17th consecutive month.
While the casinos in Southern Nevada enjoyed some success, the gaming business in Northern Nevada continued to suffer. Washoe County casinos reported a 4.2 percent decline in gross win in November; South Lake Tahoe was off 26.6 percent; Carson City was off 10.5 percent and Elko gaming revenue fell 8.7 percent.
Streshley cautioned that "one month is not a trend." But he said he received good feedback from casinos on their New Year's business. In a depressed economy, he said the games are usually the first to rebound. He said this was seen in the high-end play on the Strip. Slot machine play is slower to recover, he said.


text:
Home / American Football / LIVESTREAM: Germany – Braunschweig New Yorker Lions @Cologne Crocodiles, Sat. May 11, 5p CEDT (11a EDT)
LIVESTREAM: Germany – Braunschweig New Yorker Lions @Cologne Crocodiles, Sat. May 11, 5p CEDT (11a EDT)
By Roger Kelly on 05/11/2019@RogerKelly18
The Cologne Crocodiles (0-1) welcome the 1-0 Braunschweig New Yorker Lions to the unfriendly confines of Sportpark Höhenberg Köln stadium in Cologne, Saturday, May 11 for the second game in a back-to-back, home-and-home series in the German Football League's second weekend of play.
Last week, the Lions downed Cologne 23-7 after scoring 13 points in the third quarter and then holding on for the win. In that game, Braunschweig quarterback Brandon Connette completed just 9 of 22 passes for 135 yards and one touchdown. He also scored on a one yard plunge. He was under pressure from the Crocodiles front seven all game and was sacked twice as the offense struggled. In fact, the Lions special teams accounted for the third major score returning a blocked punt for a touchdown.
For Cologne, QB Jan Weinreich threw for 154 yards and a touchdown but was picked off twice. RB Colby Goodwyn, who was the 2nd leading rusher in the GFL with Hamburg in 2018, led all rushers with 18 carries for 84 yards. He will definitely be a huge factor for the Crocodiles in today's game.
This is a tough game to predict. With home field advantage, Cologne could pull of the upset although the Lions have never lost to Cologne since the Crocodiles entered the GFL in 2017.
Watch the game live here. Braunschweig New Yorker Lions @Cologne Crocodiles, Sat. May 11, 5p CEDT (11a EDT)
Roger Kelly is an editor and a writer for AFI. A former PR Director the B.C. Lions of the Canadian Football League for 7 years, he now lives in Sweden writing about and scouting American Football throughout the world.
Related ItemsAmerican FootballBraunschweig New Yorker LionsCologne CrocodilesEuropeGerman Football LeagueGermanyLivestreamNews
← Previous Story LIVESTREAM: CEFL – Koc Rams (Turkey) @Calanda Broncos (Switzerland), Sat. May 11, 6p CEDT (12p EDT)
Next Story → LIVESTREAM: Germany – Munich Cowboys @Schwäbisch Hall Unicorns, Sat. May 11, 5p CEDT (11a EDT)


text:
Home > California > Los Angeles County
Oakwood School
11230 Moorpark Street/11600 Magnolia Blvd
www.oakwoodschool.org
Oakwood School Photo #2
Oakwood is a K-12 coeducational independent day school, founded in 1951, where young people prosper in thought and imagination, in competence and character, as individuals and as members of a school community.
We believe that a school environment should be supportive and stimulating, should hold intellectual attainment in high regard, and should encourage children to exercise increasing independence, to take meaningful risks, and to reflect on their experience.
We seek teachers who are competent in their disciplines and creative in their approaches; who are committed to the whole of school life; and who dedicate themselves to the growth and development of their students.
We seek children who are capable, motivated, and characterized by a variety of talents, interests, learning styles, and backgrounds.
We seek parents who subscribe to our aims and values and are committed to working in partnership with the school.
Our program is college preparatory, but we are equally concerned with the quality of children's experiences in the present.
We believe that school must be rewarding in its own right, and not merely a step along a pathway to college.
Grades: Kindergarten-12
Yearly Tuition: $29,680
Application Deadline: Dec. 16
Oakwood School places among the top 20% of private schools in California for:
Affordability Least expensive tuition
School History Oldest founding date
School Membership(s)School Assoc. National Association of Independent Schools (NAIS)
Western Association of Schools and Colleges (WASC)
California Association of Independent Schools (CAIS)
Educational Records Bureau
Grades Offered Grades Kindergarten-12
Number of AP Courses 15 courses
Advanced Courses American Government, American History, Art History, Biology, Calculus AB, Calculus BC, Chemistry, Computer Science AB, English Language, English Literature, French Language, Human Geography, Music Theory, Physics C, Spanish Language, Statistics,
Admission Deadline Dec. 16
Yearly Tuition Cost $29,680
Tuition Notes K-6: $29,680 7-12: $34,800
Admissions Director Nancy Goldberg K-6/Jenna Frost 7-12
Admissions Associate Yvette Poydras
Sports Archery, Badminton, Ballet, Baseball, Basketball, Cross Country, Dance, Equestrian, Field Hockey, Flag Football, Paddle Tennis, Soccer, Softball, Tennis, Track and Field, Ultimate Frisbee, VolleyballArchery, Badminton,
Ballet, Baseball,
Basketball, Cross Country,
Dance, Equestrian,
Field Hockey, Flag Football,
Paddle Tennis, Soccer,
Softball, Tennis,
Track and Field, Ultimate Frisbee,
ExtracurricularsExtra-curric. Book Club, Breakdancing, Ceramics, Community Service, Cultural Awareness, Debate, Drawing, Fencing, Film/Video, Glee, Jazz Band, Newspaper, Orchestra, Painting, Photography, Poetry, Robotics, Sculpture, Stage Craft, Student Council, Theater, Yearbook
Immersion: An intensive two-week period in the academic year for 7-12 grade students to be fully immersed in rich and challenging learning experiences in ways not possible during the regular academic schedule. Immersion courses are experimental: learning is hands-on, exploratory, and in the field, well beyond the boundaries of the regular classroom. Courses are designed to spark passion, to help students become deeply and personally involved in their work, and to encourage opportunities for service learning in the wider community. Immersion courses are intended to stimulate curiosity, creativity and imagination, along with a deepened understanding of interesting and worthwhile subject matter. Some courses include: International Travel (Costa Rica, Oxford, Spain, Sierra Leone, China), Aircraft Design, Computer Animation, Fashion Design, Fencing, Marine Biology, Grassroots Activism, High Tech Golf, Modern Food Revolution, Race Matters: Cinematic Approaches, Young Investors, and more.
People that viewed Oakwood School also viewed these schools: The Buckley School, Campbell Hall School, The Wesley School, Brentwood School and Bishop Alemany High School.
The Buckley School
3900 Stansbury Avenue
(818)783-1610 3.9 K-12
Campbell Hall School
(Episcopal)
Grades: K-12 | 1106 students
4533 Laurel Canyon Blvd
The Wesley School
Grades: K-8 | 306 students
4832 Tujunga Ave
(818)508-4542 0.6 K-8
Brentwood School
100 South Barrington Place
Bishop Alemany High School
(Roman Catholic)
Grades: 9-12 | 1347 students
11111 Alemany Dr
Mission Hills, CA 91345
The nearest high school to Oakwood School is Harvard-Westlake School (1.0 miles away)
The nearest elementary school is St Charles Borromeo School (0.5 miles away)
The nearest preschool is Abc Little School (0.7 miles away)
Oakwood is an exceptionally warm/nurturing but academically strong school. My daughter is a junior there and came from a not very rigorous middle school. The transition could have been brutal but the faculty worked together to support her and she's now taking honors Physics, AP US history etc. While Oakwood has a rep as an arty school (which it is) my daughter found her passion in the amazing STEAM department and willingly took math in summer school so that she could get to Calculus sooner. And I know this all makes her sound like she's just a machine - but she isn't. She's made wonderful friends and loves takes sculpture and ceramics. Oakwood offers everything she never knew she wanted to study. Basically, Oakwood doesn't just make strong students, it makes great kids.
- Posted by Parent - Mandy C
Endorse Oakwood School. Endorsements should be a few sentences in length. Please include any comments on:
11306 MOORPARK ST UNIT 12
STUDIO CITY, CA
4295 BAKMAN AVE
11121 LANDALE ST
4252 FAIR AVE UNIT 17
realtor.com™View Homes Near Oakwood School
The average acceptance rate in North Hollywood, CA is 82% (read more about average acceptance rates across the country).
SCHOOL BY TYPE (CA):
Summer School Programs (1,060)
Open houses in California (68)
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Popular Ubuntu computer company System76 has just made a minor, but noticeable update to its line of small but powerful Ubuntu laptops.
This one is for the people who live in the UK/European countries.
System76 now offers the ability to choose an alternative keyboard layout, featuring Pound, Euro, and Alt GR keys. This upgrade is only only on their line of laptops, currently there is no word on their desktop counterparts yet.
At the time of this post, keyboard prices will have you tack on an extra $33 USD. Also not known is if they will actually ship the US keyboard as well, because you are paying more money to get an alternative keyboard.
While this might sound good and all, the keyboards are available just yet, according to their website the estimated timed arrival set for August 13th, presumably their time.
If you have any thoughts, let me know of below.


text:
Ibsen Henrique de Castro (* 17. Januar 1938 in Morrinhos, Bundesstaat Goias, Brasilien; † 30. Dezember 2020 in Goiânia, Bundesstaat Goias, Brasilien) war ein brasilianischer Politiker.

Leben und Wirken
Er studierte Wirtschaftswissenschaften und arbeitete zeitlebens als Ökonom für die Öffentliche Hand. Von 1971 bis 1974 sowie von 1979 bis 1983 war er Agrarminister von Goias. Als Abgeordneter im Landesparlament von Goias war er von 1975 bis 1983 durchgehend tätig, von 1977 bis 1979 auch als Vorsitzender des Landesparlaments und damit neben dem Gouverneur der wichtigste Mann des Bundesstaates. Im Bundesparlament in Brasilia vertrat er den Bundesstaat Goias von 1983 bis 1987.

Castro war ein Parteienwechsler, so gehörte zeitweise zur Arena-Partei, zur PDS und zur PMDB. Seine politische Karriere beendete er mit einer letzten Amtszeit als Abgeordneter im Landesparlament von Goias in der Zeit von 1995 bis 1999.

Am 30. Dezember 2020 starb Ibsen Henrique de Castro im Alter von 82 Jahren in der Hauptstadt des Bundesstaates Goias an den Folgen einer COVID-19-Erkrankung. Die Stadt ordnete drei Tage Trauer an.

Quellen
https://portal-legado.al.go.leg.br/deputado/perfil/deputado/1673
https://diariodeaparecida.com.br/governador-ronaldo-caiado-manifesta-pesar-pela-morte-do-ex-deputado-federal-ibsen-henrique-de-castro/
http://www.podergoias.com.br/materia/3789/vitima-da-covid-19-morre-ibsen-de-castro-aos-82-anos

Politiker (Brasilien)
Brasilianer
Geboren 1938
Gestorben 2020
Mann

redpajama_set_name: RedPajamaWikipedia


text:
The Astadhyayi of Panini (Volume VII)
S.D. Joshi (Author) J.A.F. Roodbergen (Author)
Astadhyayi literally means 'collection of eight adhyayas'. This multi-volume set is a translation and critical explanation of one of the greatest monuments of human intelligence, and differs greatly from the translations published earlier. Panini provides with the precise knowledge of an old Indo-Aryan language. No other language to this day has been so perfectly described. Why publish another edition of the text of the Astadhyayi, and another translation? The short answer is that this work differs from the rest in at least seven respects, as follows:01/ Attention is paid to the interpretation of the multi-purpose particle ca in Panini's sutras. This has a direct bearing on the division of the rules, and, therefore, on their interpretation.02/ The conventions of anuvrtti and nivritti of rules or parts of rules have been systematically applied. This also has a direct bearing on the interpretation of the rules.03/ On the basis of above 1 & 2, an attempt is made to identify interpolations and historical layers in the text of the Astadhyayi as presented by the KV and followed by all Indian and Western editors.04/ Examples of rules are checked wherever possible against attested usage outside grammatical literature. Here the work done by the Deccan College Sanskrit Dictionary project proved to be very useful.05/ As regards conflict-solving procedures adopted in the Astadhyayi, tradition has both confused and multiplied conventions. This led to the phrasing of exceptions and counter-exceptions to the point that nearly anything goes, somewhat like what happened to Marxist doctrine. In this work, these procedures have been re-defined and provided with a clear domain of their own. They have also been simplified. Both the re-definition and the simplification have been carried out on the basis of a strict interpretation of the Astadhyayi itself.06/ In the interpretation of the Astadhyayi, apart from the Mahabhasya, importance has been attached to examples transmitted by the KV, different from those provided by Patanjali, and which may provide a clue as to the authentic meaning of a Paninisutra.07/ Whenever tradition has manifestly re-interpreted a rule to accommodate usage, this has been pointed out. PANINI's historical existence is generally accepted. According to tradition he hails from a place in the Northwest of the subcontinent, now in Pakistan. His date is a vexed question, but editors of the present volume place is around 550 BC, which makes him a slightly older contemporary of the Buddha. It is certain that Panini took his place in a line of grammarians and teachers of Sanskrit. He is known to have mentioned ten predecessors by name. It goes without saying that he must have borrowed a considerable quantity of material, whether literally or in a modified form. But all this cannot hide his originality as a system-builder, his amazing ability to formulate a comprehensive grammatical system. If it is accepted that Panini was the author of the Astadhyayi in the sense that he invented and developed the grammatical system on which the Astadhyayi is based, the question may be asked whether Panini was the author of the Astadhyayi as know it. This question is to be decided on the basis of inconsistencies in the present text of the Astadhyayi. Editors of this work assume that Panini was not the author of the Astadhyayi in the form in which we know it. Rules have been interpolated. There is evidence that whole sections have been added. And finally, it is doubtful whether the rules dealing with the Vedic language formed part of the original body of rules.
The Astadhyayi of Panini (Volume XIII)
The Astadhyayi of Panini (Volume X)
The Astadhyayi of Panini (Volume XII)
The Astadhyayi of Panini (Volume XI)
Title The Astadhyayi of Panini (Volume VII)
Author S.D. Joshi
J.A.F. Roodbergen
Publisher Sahitya Akademy
length 151p.


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